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SSM HEALTH REHABILITATION HOSPITAL-OKC
STAFFING AND DELIVERY OF CARE
Tag No.: A0392
Based on record review and interview, the hospital failed to ensure the patient received safe delivery of care for one (pts. #1) of 20 patients reviewed.
Findings:
Pt #1
A review of medical record showed the patient was admitted to the facility on 08/21/2024 and had a complete skin assessment that showed no wound to posterior area. A skin assessment completed on 09/23/24 showed a wound to poterior area that measured 6cm x 3cm x 0.2cm. Documentation showed no wound documented between 08/21/2024 and 09/22/2024. Documentation showed no indication of when wound developed.
During an interview on 12/11/2024 at 11:00 pm, Staff member O stated they performed the initial skin assessment at which time the patient's posterior side was clear with no wounds noted.
NURSING CARE PLAN
Tag No.: A0396
Based on record review and interview, the hospital failed to ensure the nursing plan of care was implemented and documented in the medical record for 17 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17) of 20 patients reviewed.
Findings
A review of medical records showed 17 (Pt #1 - #17) of 20 records reviewed had no plan of care developed or documented for the following patients:
Pt. #1 admitted on 08/21/24 showed no PoC as of DC date 09/24/24.
Pt. #2 admitted on 02/04/24 showed no PoC as of DC date 02/10/24.
Pt. #3 admitted on 03/04/24 showed no PoC as of DC date 03/06/24.
Pt. #4 admitted on 03/14/24 showed no PoC as of DC date 03/20/24.
Pt. #5 admitted on 04/15/24 showed no PoC as of DC date 05/01/24.
Pt. #6 admitted on 04/29/24 showed no PoC as of DC date 05/04/24.
Pt. #7 admitted on 05/09/24 showed no PoC as of DC date 05/17/24.
Pt. #8 admitted on 05/28/24 showed no PoC as of DC date 06/05/24.
Pt. #9 admitted on 06/15/24 showed no PoC as of DC date 06/25/24.
Pt. #10 admitted on 07/01/24 showed no PoC as of DC date 07/12/24.
Pt. #11 admitted on 07/05/24 showed no PoC as of DC date 07/11/24.
Pt. #12 admitted on 07/19/24 showed no PoC as of DC date 08/01/24.
Pt. #13 admitted on 07/30/24 showed no PoC as of DC date 08/11/24.
Pt. #14 admitted on 09/12/24 showed no PoC as of DC date 09/12/24.
Pt. #15 admitted on 08/01/24 showed no PoC as of DC date 08/15/24.
Pt. #16 admitted on 09/28/24 showed no PoC as of DC date 10/04/24.
Pt. #17 admitted on 10/31/24 showed no PoC as of DC date 11/14/24.
During an interview with Staff O on 12/11/2024 at 9:00 am., they stated the nursing plans of care were not documented as required.