Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 16: NURSING SERVICES 16.00.10 Plan of care Frequency of the citation: 26%
■ Medical records lacked documentation of screening to identify risk for self or others. ■ One of three ED medical records for patients assessed at high risk for self-harm had a one-and-a- half-hour delay for initiating 1:1 observation as required by facility policy. ■ The hospital lacked evidence of a policy related to an annual environmental risk assessment. ■ The hospital lacked evidence of an environmental risk assessment for the emergency department, ICU, med-surg, OB and pediatric units. ■ The environmental risk assessment did not identify any environmental safety risks or strategies to minimize risks. ■ The adult BH unit was found to have multiple ligature and/or risk points (more than 40 items) in the environment. These include hospital-style beds in some rooms, chairs, tables, sink faucets, door handles, electronic equipment, power cords, and two open nurses' stations accessible to patients via a low counter with access to items that can easily be thrown (computer, chairs, rolling carts, printers, etc.), office supplies, and telephone cords. The hospital’s environmental risk assessment listed these items and documented a mitigation strategy to increase levels of observation/ intervention according to assessments for suicidality. Medical record review of patients admitted with a diagnosis of suicidal ideation lacked evidence of required interventions for suicidal patients as identified on the environmental risk assessment.
Overview of the requirement: Each patient has an individualized nursing care plan based on assessment of treatment goals, physiological and psychosocial factors, and discharge planning. The care plan is kept current through updates and revisions in response to ongoing assessments. Comment on deficiencies: Hospital policy and medical records are reviewed to determine compliance. Most findings noted care plans that did not reflect assessment data or were inconsistent with medical care plans. Examples of ACHC Surveyor findings: ■ Hospital policy requires a nursing care plan initiated within eight hours of admission. Medical records lacked evidence of care plan implementation within this time frame. ■ Medical records lacked evidence of an established nursing care plan once a risk was identified on admission, as required by policy. ٝ Two of 30 nursing care plans lacked evidence of skin interventions required as indicated by the admission risk assessment; One of 30 nursing care plans lacked evidence of pain interventions required; Seven of 30 nursing care plans lacked evidence of VTE interventions. ■ Records did not contain care plans consistent with the physician's assessment for medical care. ٝ The physician identified diabetic care and respiratory (CPAP) needs, which were not reflected in the care plan. ٝ The physician identified that seizure care was required, which was not reflected in the care plan. ٝ The physician identified airway protection needs that were not reflected in the care plan. ٝ The physician identified coagulation needs that were not addressed in the care plan.
Compliance tips for:
These two standards work together for the safety of patients and others. Although all risks cannot be eliminated, hospitals are expected to: 1. Identify patients at risk for intentional harm to self or others.
Nerd Newbies (understand the requirement)
2. Identify environmental safety risks for such patients. 3. Provide education and training for staff and volunteers.
■ Audit patient records for inclusion of screening assessments. ■ Audit for annual environmental risk assessments for each patient care department. ■ Train staff on screening process to include risk of self-harm and risk of harm to others. ■ Bring awareness to what constitutes a ligature risk point and train staff on required mitigation actions when an at-risk patient is present.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
Compliance tips for: Nerd Newbies
Each patient has an individualized plan of care. This standard focuses on the nursing care component, ensuring that it is consistent with the physician’s plan for medical care but addresses patient goals and other factors, as well as discharge planning. ■ Audit records of nursing care plans to ensure they are congruent with assessments and medical care plans.
(understand the requirement)
Nerd Apprentices (audit for excellence)
■ Promote integrated, multidisciplinary care and communication by developing the nursing care plan in coordination with other disciplines.
Nerd Trailblazers (prepare the path for others)
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