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Based on hospital policy and procedure review, open and closed medical record review, and staff interview, the facility's nursing staff failed to supervise and evaluate patient care by failing to ensure a comprehensive plan of care was developed for 1 of 4 sampled patients with hearing deficits (Patient #2).

Findings included:

Review of the facility policy titled "Interdisciplinary Care Planning and Documentation" review/revised: 10/2017 revealed, "POLICY Planning for care, treatment, and services is individualized to meet the patient's unique needs. ... 2. Plan of Care...The plan of care assessment includes: i. Daily care needs/daily goals..."

Closed medical record review for Patient #2 on 02/19/2019 revealed, he was a 93 year old male admitted on 01/23/2018 through 02/10/2018. Review of the "Valuables/Belongings" document, dated 01/23/2019, revealed RN #6 noted he presented with hearing aids. Review of the History and Physical (H&P) 01/23/2018 at 1536 revealed the plan was to initiate a comprehensive interdisciplinary plan of care with physical therapy, occupational therapy and rehabilitation nursing. Review of the Occupational Therapy (OT) Initial Evaluation note on 01/24/2018 at 0700 revealed an OT treatment plan to include: "Needs assistance for personal care, history of falls, and cognitive deficits due to CVA (Cerebral Vascular Accident, stroke) ... Assessment ...OT Rehabilitation Potential: Fair..." The therapist noted the evaluation was "... Limited due to pt. (patient's) global aphasia (patient's limited ability to recognize words and understand little or no spoken language)..." Review of the Speech Language Pathology Therapy (SLP) initial evaluation on 01/24/2018 at 1300 by SLP #1 revealed, "... Adaptations for Hearing Deficits: wears aids, but still impaired..." Review of the Physical Therapy (PT) #2 initial evaluation on 01/24/2018 at 1654 revealed, "...Communication: Impaired, Other: Pt was able to respond better when PT spoke in deeper tones of voice while pt was wearing his hearing aids..." Review of nursing progress notes revealed on 01/24/2018 at 0900, RN #7 noted the patient had hearing aids. Review of nursing assessments revealed "hearing loss" was documented in the "Sensory" section of the assessment. Review revealed a hearing deficit was identified during the initial SLP and PT evaluations, in addition to the cognitive deficits noted in the initial OT evaluation. However, there was no documented Comprehensive Interdisciplinary Treatment Plan with patient specific goals, interventions, or anticipated target dates of achievement by OT, SLP, PT, Nursing, or other members of the team addressing the patient's auditory needs. Continued review revealed the was no documented evaluation of the patient's ability to assume responsibility for the safe keeping and application of his hearing aids, alternative teaching methods to ensure comprehension during daily therapy sessions or verification that the hearing aids were in use and operational on a day-to-day basis.

Interview with OT #1 on 02/20/2019 at 1550 revealed, she performed the initial OT Evaluation on 01/24/2018 at 0700 for Patient #2 which included an assessment of his functional ability to perform standard personal care in a safe manner. OT #1 revealed, "...I would ask the patient if he wears dentures or hearing aids. A lot of times the doctors would put HOH (hard-of-hearing) or hearing aid required for communication." Interview revealed, "If the patient was functioning and we were communicating without any apparent barrier, it wouldn't probe me to look further as long as he was able to participate and perform the tasks asked of him."

Telephone interview with SLP #1 on 02/20/2019 at 1615 revealed that she recalled caring for the patient. The therapist shared that there are "Typically notes on the communication board to communicate to staff facts that are pertinent such as, hearing aids ..." Interview revealed, "I feel like I made the mistake that I did not notate in the chart the patient's use of dentures or hearing aids."
Interview revealed, the SLP#1 did not recall documenting the patient's use of hearing aids, except for her initial evaluation on 01/24/2018 at 1300.

NC00147901