HospitalInspections.org

Based on record review and interview the hospital failed to ensure that the nursing staff kept current, a nursing care plan for each patient, in that 7 of 7 (Patient's #4, #5, #6, #7, #8, #9, and #10) patients had care plans that did not evidence updates to keep current the goals met or not met during the patient's stay, and the care plans did not evidence an update when procedures were performed.

Findings Included:

Patient #4's, #5's, #6's, #7's, #8's, #9's and #10's care plans did not evidence updates to keep current the goals met or not met during the patient's stay, and the patient's care plans did not evidence an update when a procedure was performed.

Patient #4's, #5's, #6's, #7's, #8's, #9's, and #10's care plans did not evidence the insertion of a PICC (Peripherally Inserted Central Catheter) line during the patient's stay.



The policy titled Plan of Care-Individualized and Interdisciplinary, dated 6/6/15 reflected...The plan is continuously evaluated and monitored for effectiveness in meeting its intended goals...A. Modifications are made to the plan of care...based on reassessment of the patient at specific intervals and related to the following elements: 1. Progress toward goals. 2. Failure to make progress...5. Other significant data...

During an interview on 2/8/17 at 2:45 PM, Personnel #2 was presented with the findings. Personnel #2 stated the updates were in another area of the care plans. Personnel #2 printed the POC Modification sheet which only reflected a date a modification was performed, but not any information of what the modification entailed.

Based on record and interview the facility failed to ensure completion of the medical records within 30 days following discharge in that, 6 of 7 (Patient #5, #6, #7, #8, #9, and #10) patient discharge summaries were not completed within 30 days following discharge.

Findings Included:

Patient #5's discharge summary reflected a discharge date of 7/30/16 and the discharge summary was completed on 9/20/16.

Patient #6's discharge summary reflected a discharge date of 11/7/16 and the discharge summary was completed on 1/22/17.

Patient #7's discharge summary reflected a discharge date of 12/12/16 and the discharge summary was completed on 1/23/17.

Patient #8's discharge summary did not reflect a discharge date. Patient #8's medical record reflected a discharge date of 12/20/16. Patient #8's discharge summary was completed on 2/1/17.

Patient #9's discharge summary reflected a discharge date of 11/30/16 and the discharge summary was completed on 1/12/17.

Patient #10's discharge summary reflected a discharge date of 7/19/16 and the discharge summary was completed on 9/20/16.

During and interview on 2/8/17 at 1:30 PM Personnel #2 confirmed the discharge summaries were out of compliance.

Based on record review and interview the hospital failed to ensure a properly executed informed consent form for the operation was in the patient's chart before surgery in that, 5 of 7 (Patients #4, #5, #7, #8, and #9) Patient's informed consents were not completed prior to having PICC line placement.

Findings Included:

Patient #4 underwent a PICC line placement on 8/2/16, the informed consent reflected the physician signed the consent on 8/8/16 six days after the PICC line was placed.

Patient #5 underwent a PICC line placement on 7/10/16, the informed consent was not signed by the physician.

Patient #7 underwent a PICC line placement on 12/1/16, the informed consent reflected the physician signed the consent on 12/18/16 fifteen days after the PICC line was placed.

Patient #8 underwent a PICC line placement on 12/9/16, the informed consent reflected the procedure to be performed was not listed on the consent and the consent was not signed by the physician.

Patient #9 underwent a PICC line placement on 11/17/16, the informed consent was not signed by the physician.

The policy tilted Informed Consent dated 6/6/15 reflected...The risks, benefits, alternatives and possible complications of the proposed care, treatment or service shall be explained by the practitioner to the patient prior to asking the patient to sign the Informed Consent...

During an interview on 2/8/17 at 1:30 PM, Personnel #2 verified that some of the consents did not reflect a physicians signature or the physician had signed the consent after the procedure was completed.