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Based on interview and record review, the Registered Nurse (RN) failed to ensure one of eight (#5) sampled patients received the nursing care for the activity of daily living (ADL) for bathing, and personal hygiene.

Findings:

1. During patient interview on 05/16/2011 at 11:30 AM, patient #5 stated that he/she was scheduled for bathing every day. Patient #5 further stated that he/she only had one bath since admission, and stated "you can probably smell me from standing over there."

Medical record review revealed that patient #5 was admitted on 05/10/2011 and needed total care in bathing and hygiene.

Review of the Nursing flowsheet documentation for the month of May, 2011 revealed that patient #5's Activity of Daily Living was not done, and it was written that this activity did only occur on one day of the six days that patient was in the hospital, which was on 05/14/2011 at 5:00 PM. Further review revealed that there were not any Certified Nursing Assistants (CNA's) Activity of Daily Living documented as done for patient #5, the other than one complete bed bath on May 14, 2011.

Interview with the nurse for patient #5 on 05/16/2011 at 1:00 PM confirmed that patient #5 is to be bathed every day by nursing staff.

Interview with the Director of the Surgical Unit (RN) on 05/16/2011 at 1:10 PM revealed that she is not aware why the care was not provided, that the activity did not occur, and that the patient is to be bathed every day.

Further interview with the Director of the Surgical Unit on 5/16/2011 at 1:30 PM revealed that she has spoken to the family member and patient #5 and has confirmed that he/she has not been bathed as scheduled. Although the care and documentation still remained that care of ADL's have not been provided.

Based on observations, interviews and record review revealed that the facility failed to follow their Policy and Procedure to ensure that hospital personnel implemented infection prevention and control process that would reduce the risk of infection to patients.

Findings:

1. Observation of Foley Catheter care, on 05/16/2011 at 11:30 AM with Certified Nursing Assistant #1 (CNA#1) who was providing care for patient #6 revealed the following:

Supplies were gathered. The supplies consisted of :
Multiple towels
Multiple washcloths
1 Wash Basin with soap in the water

CNA #1 took a washcloth placed it into the soapy water basin and wiped patient 6's penis, then placed the dirty contaminated washcloth on the sink countertop next to the bed.

Then she took a second cloth, wet it with the soapy water and wiped the scrotum, then placed the dirty contaminated washcloth on the sink countertop next to the bed.

At this point CNA #1 took a third cloth, placed it in the soapy water and wiped the resident from the base of the penis toward the meatus and over the top of the urethra, without changing position on the cloth, then placed the dirty contaminated washcloth on the sink countertop next to the bed.

Interview on 05/17/2011 at 1:30 PM with CNA #1 confirmed that she had placed these contaminated washcloths on the clean sink countertop.

2. Observation of Foley Catheter care, on 05/17/2011 at 10:30 AM with CNA #2 who was providing care for patient #7 revealed the following:

Supplies were gathered. The supplies consisted of :
One towel
One washcloth
1 Wash Basin with soap in the water

CNA #2 took a washcloth placed it into the soapy water basin and wiped patient 7's scrotum, the base of his penis, the meatus, and then wiped down the Foley catheter tubing with the dirty contaminated washcloth, contaminating the Foley catheter tubing.

Interview on 05/17/2011 at 11:00 AM with CNA #2 confirmed that she used the same washcloth to wipe all these areas during Foley catheter care with the same washcloth, which contaminated the tubing when she wiped the catheter tubing.

3. Review of the facility's Infection Control Policy and Procedure regarding Foley catheter care revealed the two CNAs did not follow the facility's policy.

4. Interview on 05/17/2011 at 2:00 PM the facility's Director of the Surgical Unit confirmed that the facility's Infection Control Policy and Procedures regarding Foley catheter care were not followed, and that this was improper Foley catheter care that was provided to patients #6 and #7.