109.31 Principle
There shall be evidence that the
nursing service provides safe,
efficient, and therapeutically
effective nursing care through the
planning of the care of each inpatient
and the effective implementation of
nursing care plans. In any case, where
it is determined that a nursing care
plan is not necessary, that decision
shall be documented in the medical
record.
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Observations:
Based on review of medical record (MR) and facility documents and interview with facility staff (EMP), it was determined that the facility failed to follow adopted policy by failing to update the nursing care plan to ensure the implementation of safe and therapeutic nursing care in one of one patient (MR1).
Findings Include:
Indiana Regional Medical Center Subject: Assessment/Reassessment Department of Origin: Interdisciplinary/Organizational policy and procedure dated October 19, 2022. "Purpose: To ensure that all patients receive the appropriate assessment (including initial/screening and reassessment) provided by qualified individuals within the organization. Policy: All age groups of patients at Indiana Regional Medical Center receiving inpatient, outpatient, ER services will have an initial assessment and appropriate follow-up assessments, based upon their individual physical, psychological, and social/cultural needs and age specific needs. This assessment process will determine the need for care/treatment and the type of care to be provided throughout the continuum of care and prioritize. ... Assessment Framework The assessment framework will be structured around two components: initial screening and assessment and reassessment of all patients as appropriate to the clinical discipline and individual patient condition changes. I. General Information generated via a patient's assessment will be integrated with other disciplines to identify and prioritize the patient's needs for care and treatment. The various disciplines will share and provide information about their portion of the patient assessment relevant to their scope of care. ... Assessment of patients needing nursing care in all settings (departments) will be performed by an RN ... II. Initial/Screening Assessment ... The following considerations are guidelines for healthcare providers in the design of a discipline-specific assessment. The assessment process will be collaborative to facilitate, identify and prioritize the patient's needs, determine care/treatment and the continuum of care when discharged. ... B. ... G. The patient's functional assessment, specifically for rehabilitation services, and as appropriate to other ancillary departments. ... III. Reassessment A. Each clinical discipline will establish when the patient is to be reassessed. ... IV. Scope and Responsibilities of Involved Disciplines ... D. 1. At the time of admission, each patient will have his/her needs assessed by an RN. 2. The nursing admission history will be completed by the RN as soon as possible upon arrival to the nursing unit, but will not exceed the parameters for each unit. The nursing admission history will be completed by the RN as soon as possible upon arrival to the nursing unit, but will not exceed established parameters for each unit. The nursing history /assessment will include: Evaluation of biophysical, functional, psychosocial, characteristics. ... 3. a. When the history/assessment has been completed the Registered Nurse will identify the patient care needs or problems and develop a Care Plan based on identified needs. Any need/problem identified will be referred to the appropriate discipline for further assessment in accordance with their established criteria. b. In-patients will be assessed by an RN at least once every 24 hours to determine if nursing cared (sic) needs have been changed and will update the plan of care accordingly. ... ."
Review of the patient's medical record (MR1) revealed inconsistent documentation of bowel assessment that included no documented evidence of a bowel movement from July 6, 2023, through July 26, 2023.
Continued review of MR1 revealed, "Critical Care Progress Note ... 7/28/2023 ... 10:49 ... 7/26 ... no BM yet 7/27... no BM. ... 7/28 ... avoid additional prn sedative/hypnotics, likely still has a great deal sequestered in gut due to lack of BM for several days ... ."
Further review of the MR1 revealed inconsistent documentation of the patient's bowel status on the interdisciplinary plan of care (IPOC) beginning on July 9, 2023, through discharge July 31, 2023.
Review of facility electronic mail documentation dated May 14, 2024, at 2:27 PM from EMP2 revealed, "... They consistently listened to bowel sounds noted in all quadrants but not able to assess last movement (noted or not noted) 7/5 to 7/27 is correct, unfortunately. ... ."
Review of facility electronic mail documentation dated May 14, 2024, at 3:49 PM from EMP2 revealed, "... the IPOC was initiated on 7/9/23 and documented against on the dates shown in the screenshot. Several day (sic) were missed (7/17, 7/18, 7/20, 7/21, 7/23, 7/27 and 7/28). At the discharge, all IPOC interventions must be resolved based on the process flow we did. The expectation should be documentation every day."
| | Plan of Correction - To be completed: 07/12/2024
Review of IPOC Cerner Process with ICU, Educators, 6th Floor Manager using Ultimate Kronos Group computer module.
Responsible: Exec Dir Quality
Complete 6/5/2024
Immediate Education on existing policy for Independent Plans of Care- All RNs and LPNs, facility-wide
Responsible: Professional Development
Completion due: 7/12/2024
Goal: UKG online over 30 days- 85%
Create Standing Order for Bowel Management
Responsible: Clinical Pharmacist
Complete: 6/10/2024
Approval process completion: July Board of Director's meeting
Revision recommendations for EMR Independent Plan of Care to IPOC Team
Responsible: IT
Adding visual indicators for BM status and GI Symptoms as digital reminders
Complete: 6/10/2024
Re-education on new standing orders and process flow- all RN's and LPN's facility-wide
Responsible: Professional Development Team
Completion Date: 8/30/2024
Monitoring on ICU and 6S
Responsible: All inpatient unit nursing managers to pull reports and randomly select 10 patients assigned to IPOC for Bowel Dysfunction per month. Review will include documentation and action if "not met" or "progressing" with Reason and Action in place; Feedback to staff for immediate coaching based on Just Culture algorithm.
Goal: Monthly until 100% compliance
Results of audits will be reported to the Quality Patient Safety Council starting with July 26 meeting, and the July Board of Directors meeting until compliance is met for 1 month at 100%.
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