HospitalInspections.org

Based on a review of the policies and procedures, medical record, and interview, it was determined the Hospital did not require the nursing staff to:

1) offer a daily bath/shampoo to Patient #1; and

2) document the percentage of each meal eaten by Patient #2.

Findings include:

1) The policy "Adult Patient Standards of Care" requires: "...All patients will be provided an opportunity for personal hygiene at least daily...."

The nursing staff documented patient #1 refusing a bath/shampoo on 02/13/11, at 0800 and 1100.

The Quality Specialist confirmed the nursing staff did not documented offering a bath/shampoo on either 02/11/11 or 02/12/11.

2) The policy "Adult Standards of Care" requires: "...Management of the patients' nutrition and hydration includes:...Intake and Output...."

On 05/07/12, the Clinical Nutrition Manager stated the Nutritional Services Department has approximately 20-25 diet representatives (diet rep),who are assigned to specific units, and deliver diet trays to each patient on that unit. They have a patient list that verifies what diet tray each patient is to receive. The nursing staff then pick up the trays, and record the amount consumed.

On 05/08/12, the Nurse Manager of Progressive Care Unit (PCU) and the Nurse Manager of the Medical/Surgical unit verified the nursing staff are to document the percentage of the meal consumed by each patient.

On 05/08/12, the Quality Specialist confirmed the last meal documented in patient #2's medical record was on 11/13/10, at 0800.

The Nurse Manager of PCU confirmed the nursing staff did not document Patient #2's lunch and dinner for 11/13/10, or any of 3 meals on 11/14/10.