HospitalInspections.org

Based on document review and interview, the chief nurse executive failed to assure that nursing staff supervised the care of patients by implementing the facility policy to offer daily bath or shower for 3 of 5 medical records reviewed (N2, N3, and N4).

Findings included:

1. Facility policy " Patient Personal Hygiene: Guidelines for Providing Care " , last reviewed/revised 4-11, provided on page 1 that "personal hygiene is to be offered to all inpatients at least daily". Personal hygiene was defined to include bath or shower.

2. During review of medical records on 2-27-2013 with S2:

A. i. N2 was admitted on 12-21-2012 and discharged on 2-13-2013.
ii. The medical record lacked documentation of daily bath or shower as per facility policy on the following dates: 12-22-12, 12-23-12, 12-24-12,
12-26-12, 12-27-12, 12-28-12, 12-29-12, 12-30-12, 12-31-12,
1-2-13, 1-3-13, 1-4-13, 1-5-13, 1-6-13, 1-7-13, 1-8-13, 1-9-13,
1-10-13, 1-11-13, 1-12-13, 1-13-13, 1-14-13, 1-16-13, 1-17-13,
1-18-13, 1-19-13, 1-20-131-22-13, 1-23-13, 1-24-13, 1-25-13,
1-26-13, 1-27-13, 1-28-13, 1-30-13, 2-1-13, 2-2-13, 2-3-13,
2-5-13, 2-6-13, 2-7-13, 2-8-13, 2-11-13, and 2-12-13.

B. i. N3 was admitted on 12-14-2012 and discharged on 12-17-2012.
ii. The medical record lacked documentation of daily bath or shower as per facility policy on 12-15-12 and 12-16-12.

C.i. N4 was admitted on 12-13-2012 and discharged on 12-15-2012.
ii. The medical record lacked documentation of daily bath or shower as per facility policy on 12-14-12.

3. During interview with S2 on 2-27-13 beginning at 2:00 P.M., S2 indicated:
A. N2, N3, and N4 were pediatric inpatients during the dates indicated above.
B. The medical records for N2, N3, and N4 lacked documentation of provision of daily bath or shower as per facility policy on at least a daily basis.
C. The medical records above did not indicate the patients or their families refused daily bath or shower or any medical reason to preclude a daily bath or shower if patient was ambulatory. Facility expectation is that bed baths are provided to patients who are not ambulatory.
D. The nurses and patients' family supervise the care delivered to meet patients' needs to include daily bath or shower; however, the nursing staff has not been consistent in documenting daily bath or shower in the nursing flowsheet in the medical record.
E. The medical records above documented nursing interventions of peri care when the patients experienced diarrhea, but lacked documentation of at least daily bath or shower as required by facility policy.