HospitalInspections.org

Based on medical record review and interviews, the facility failed to ensure A, three (3) of three (3) patients (Patients #2, #3 and #4) medical records included documentation of hygiene and linen changes daily or patient's refusal of hygiene and/or linen change; and B, one (1) of one (1) patients (Patients #3) medical record included documentation of patient being turned every two hours as per doctor's order.

The findings include:

Patient #2 was admitted to this facility on December 13, 2024 and was discharged on December 17, 2024. During Patient #2's hospitalization, the medical record failed to contain documentation of hygiene and linen changes, or patient refusal on December 14, 2024, December 15, 2024 and December 16, 2024.

Patient #3 was admitted to this facility on December 11, 2024 and was discharged on December 17, 2024. During Patient #3's hospitalization, the medical record failed to contain documentation of hygiene and linen changes, or patient refusal on December 13, 2024 and December 15, 2024. The medical record failed to contain documentation or lacked adequate documentation of Patient #3 being turned and repositioned every two hours, per doctor's order, December 11, 2024 through December 17, 2024.

Patient #4 was admitted to this facility on December 11, 2024 and was discharged on December 13, 2024. During Patient #4's hospitalization, the medical record failed to contain documentation of hygiene and linen changes, or patient refusal on December 11, 2024, December 12, 2024 and December 13, 2024.

In an interview on January 27, 2025, Staff Member #8, indicated that staff should be performing hygiene and linen changes at least once daily, more if needed, and then document in medical record that they were completed or document patient's refusal. Staff Member #8 indicated that documentation of turning and repositioning of a patient every two (2) hours must be completed in the medical record with the specifics of what was completed; that includes, what side the patient is lying on, is the head of the bed elevated and any support devices used.

During an interview on January 27, 2025, Staff Member #11, indicated that when staff completes hygiene and linen changes for a patient or the patient refuses, then this is to be documented in the patient's medical record. Staff Member #11 explained that it is the expectation that patients are turned every two (2) hours as per doctor's order and this must be documented in the medical record.

A facility guideline, Clinical Technician Guidelines of Care- Acute Care, not dated, revealed, in part, "...Patient Experience. Tidy bed/room...Bathing. Daily soap and water bath- required to be offered for ALL patients...Quick clean-up for stools/incontinence- use foam and dry wipes...Linen change- to be offered daily. Document bath and linen change- Recommended to document in real time before leaving patient room. If patient refuses, document this as well. Use comment section to give detail.."

The surveyor requested a facility policy and/or procedure for turning and repositioning and was given and outside source procedure, Lippincott Procedures- Pressure Injury Prevention, dated February 20, 2024. After reviewing this procedure document, it was determined that this did not address specific documentation requirements for turning and repositioning. The procedure revealed, in part, "...Documentation associated with pressure injury includes: ...Interventions used to prevent pressure injuries, response to interventions.."

Staff Member #6 confirmed that this document was the only guidance the facility has on documenting turning and repositioning of patients every two (2) hours.

Based on medical record and facility document review the facility failed to document blood product transfusions according to facility policy for two (2) of three (3) patient records sampled.

The findings include:

On January 27, 2025, surveyor reviewed three (3) sampled patient medical records.

On January 16, 2025, Patient #8 received a blood transfusion. The medical record didn't contain documentation of the following: stop time, total volume transfused, completed time and suspected transfusion reaction.

On January 16, 2025, Patient #9 received a blood transfusion. The medical record didn't contain documentation of the patient's vital signs were monitored at 15 minutes after the initiation and suspected transfusion reaction.

A review of the facility's policy "Preparing for Blood and Blood Product Transfusions at (facility name)", last revised 2/2023, indicated in part: "...Monitor patient for the first 15 minutes of the transfusion, Minimum vital signs required: 15 minutes after initiation...Blood Transfusion documentation must be performed in the EMR Flowsheet...start, stop, total volume transfused, Completed, Suspected transfusion reaction must be documented in the Flowsheet...".