At Nightingale, the surgical floor has done an outstanding job with assessing the risk of skin breakdown. In the tracer case, there was an assessment was
... [Show More] done on admission. Due to the patient’s post-operative infection and their poor nutritional intake, it was determined that the patient was at risk for skin breakdown. After making this determination, they also checked for breakdown that was already present and then ensuring that the patient was placed on a specialty bed to prevent any future breakdown.
One area where the surgical floor has not done as well is with their care plans. In our tracer case, we see that the plan of care was done initially but that it has not been updated in the last 7 days. Per the joint commission standards, the patient should be reassessed as necessary and when there are changes in their condition. Since the patient had surgery five days ago, that would be a change in their condition as they will now have surgical incisions and new wounds. Care plans will work best when they are multi-disciplinary, and all areas work together to get the patient the best care. In this case, had there been a daily review that involved all areas, it may have been found that there had never been a functional assessment done.
To improve on our care plans and make sure we are meeting Joint Commission standards, we need to have a policy that states how often care plans will be reviewed and documented. Reviewing care plans daily and performing a multi-disciplinary round would be my recommendation. This will ensure that we are doing a thorough assessment of our patients each day and making sure that they have all their needs met. To implement this change, the first step is writing the new policy. Once the policy has been written, we can start education on all nursing units. Education should be done daily in huddles, on the computer as a learning module, and in any newsletters that are sent out to the system. As an interdisciplinary tool, we will need to include ancillary departments as well. This should include PT, OT, SLP, nutrition, social work, respiratory and any other areas that are having direct patient care. This should be implemented as soon as possible to meet Joint Commission standards. [Show Less]