HospitalInspections.org

Based on document review, interview and observation, Nursing failed to supervise, document care and follow policy in 2 of 17 (Patient1 and Patient13) medical records review.

Findings Include:

1. Review of policy titled: Standards of Care: Patients with Indwelling Catheters last revised 12/2019 (policy for 10/2019 not provided) indicated stoma site care for suprapubic catheters should be completed each shift and the catheter bag can't rest on the floor.

2. Review of policy titled: Personal Hygiene last revised 6/2018 indicated that all patients shall be encouraged or assisted in grooming daily or more often as needed. "Grooming articles such as soap, shampoo...are available per patient need".

3. Review of Patient 1's medical record lacked nursing documentation of providing suprapubic cleaning of site each shift; the medical record indicated patient had a bed bath on 10/13/19 only.

4. Review of Shower Sheet book indicated that Patient 1 had a shower on 10/09/19, 10/11/19, 10/14/19, 10/16/19 and 10/18/19 (not part of medical record).

5. During tour on 01/22/20 at 9:42 am with P50 (Interim Director of Nursing) and P53 (Director of Operations), this surveyor observed a foley catheter bag resting on the floor in room 1009-1, Patient 13.

6. Interview on 01/22/20 at 9:42 am with P55 (Licensed Practical Nurse) confirmed Patient 13's catheter bag was sitting on the floor.

7. Interview with P53 (Director of Operations) on 01/22/20 at 10:55 am confirmed that Patient 1's MR lacked documentation of cleaning the stoma site of the suprapubic every shift.

8. Interview with P51 (Associate Chief Executive Officer) on 01/22/20 at 12:00 pm indicated that patients are asked daily if they want a shower; defined to include a shampoo; confirmed that Patient 1's MR lacked documentation of daily grooming or refusal.