HospitalInspections.org

Based on record review and interviews with hospital staff, the hospital does not ensure that nursing responds and provides nursing care to meet patient needs. Two (#s 8 & 9) of two patient records reviewed who were admitted as inpatients did not have evidence of nursing care provided by nursing staff for activities of daily living such as linen changes, ambulation and oral care.

Findings:

1. Surveyors were provided with paper copies of Electronic Health Records (EHR.) The hospital stated that the records provided were complete records. Later the hospital provided additional parts of the medical record from a different view on the EHR.

2. The records originally provided did not have evidence of all ADLs provided to the patients. The additional parts of the medical record provided some evidence of bathing and diaper changes.

3. The EHR records did not have evidence of linen changes, oral care or assistance with ambulation.

4. On the afternoon of 10/16/13 Staff D was asked when baths and linen changes were done? Staff D stated they were done daily and performed by nursing aides. The aides do not document in the EHR, but relay the information to the nurse who is to enter it into the EHR. The EHR does not always have evidence of daily baths and linen changes or reasons these activities are not performed.