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Based on interviews and document review the facility failed to establish responsibilities of ancillary staff. Further, nurses were not instructed on how to supervise ancillary staff to ensure all care to patients was provided. Review of patient medical records revealed 8 of 10 patients were not offered hygienic care on a routine basis (Patients #1, 2, 4, 5, 6, 8, 9, and 10).

This failure created the potential for delayed or missed patient care and poor patient outcomes.

FINDINGS

POLICY

According to Acute Care Unit Adult Standard of Care assistance with oral care will be offered every 12 hours. Offer a bathing opportunity every 24 hours. Address hair hygiene (shaving, shampooing) at least every 48 hours.

1. The facility did not offer hygiene opportunities or document ongoing assessments of hygienic needs of patients.

a) Review of patients' medical records with Clinical Informaticist #9 on 06/29/16 at 10:53 a.m. revealed 8 of 10 medical records did not address the hygienic needs of patients on a routine basis.

Patient #1, admitted 04/08/16, had no oral hygiene, bath, or linen change noted to be completed or refused on 04/09/16.

Patient #2, admitted on 04/22/16, had no oral hygiene, bath, or linen change noted on 04/22/16 through 04/25/16.

Patient #4 had no oral hygiene, bath, or linen change noted on 06/04/16 through 06/07/16.

Patient #10 had no oral hygiene, bath, or linen change noted on 04/08/16 through 04/10/16.

Similar findings were found for Patient's #5, #6, #8 and #9 in which the patients were not offered oral hygiene, bathing assistance or linen changes.

b) Review of the Acute Care Staff Meeting, dated March 2016, revealed a group discussion of improvement of workflow on Acute Care. The proposal by multiple staff was to have a change in workflow for Registered Nurses (RNs). RNs would collect at least the first set of vital signs to allow Patient Care Technician (PCT) staff to help more with activities of daily living (ADLs), linens, and baths.

During an interview, on 06/29/16 at 11:53 a.m., the Director in Inpatient Services (Director #4) stated this had been discussed, but no official policy change or role definitions had been put into place.

c) During an interview on 06/29/16 at 9:15 a.m., Registered Nurse (RN) #8 stated the expectation for hygiene was that it was charted on the patient daily. If a patient refused hygienic care, this should be charted as well. If the PCT performed hygiene care, the PCT had access to chart in the patient's medical record.

d) During an interview on 06/29/16 at 9:25 a.m. with RN #5, s/he stated the refusal of hygienic care by a patient should be charted. Hygienic care should be addressed at least daily by the RN or the PCT. Ultimately it was the RN's responsibility to ensure all care was completed.

e) During an interview, on 06/29/15 at 9:45 a.m., RN #6 stated patient care and hygiene was expected to be charted everyday by either the RN or PCT even when care was refused by the patient.

f) During an interview, on 06/29/16 at 11:53 a.m., Director #4 stated his/her expectation was that hygiene care would be charted. It was expected that either the RN or PCT would offer the care and document care provided or refused. S/he further stated the roles and expectations of the PCT needed to be further defined so all staff had the same expectations of care.

g) During an interview, on 06/29/16 at 1:00 p.m., the Chief Nursing Officer (CNO) #2 stated the expectation was to follow the Acute Care Unit Adult Standard of Care Policy and chart care or refusal of care accordingly.

Based on interviews and document review the facility failed to ensure all medication orders were appropriate and addressed during a change of patient status in 1 of 10 medical records reviewed (Patient #2).

This failure led to patients missing doses of medications, increasing risk of poor patient outcomes and side effects from abruptly stopping a medication.

FINDINGS

POLICY

According to Medication Orders Inpatient, staff must clarify any order which is not clear and legible. Change in level or care requires re-ordering of all medications. This includes post surgery.

1. The facility did not administer the patient's reported at home medication while the patient was in the hospital. Further, the facility did not address the medication status with the patient post surgery or upon discharge from the facility.

a) Review of Patient #2's medical record revealed the Transfer Medication Summary had Zoloft 100 milligrams (mg) Oral Daily 25 mg Tablet listed as a medication. The options to continue or discontinue the medication after surgery were not addressed by the physician on the order sheet.

Further review of Patient #2's medical record revealed the Discharge Order Medication Profile had Zoloft 100 mg Oral Daily 25 mg Tablet listed. The option to continue or discontinue the medication after discharge was not addressed on the order sheet by the physician. According to Patient #2's Medication Administration Record, Zoloft had not been administered during his/her stay at the facility.

b) During an interview with Clinical Informaticist #9 on 06/29/16 at 10:53 a.m., s/he stated no communication between the nurse and physician regarding the patient's Transfer Medication Summary or the Discharge Order Medication Profile could be located in Patient #2's medical record.

c) During an interview, on 06/29/16 at 9:15 a.m., Registered Nurse (RN) #8 stated the Transfer Medication Summary and the Discharge Order Medication Profile were considered physician orders. If the form did not address whether a medication was to be continued or discontinued the Registered Nurse (RN) or pharmacy staff should call the physician to clarify.

d) During an interview, on 06/29/16 at 9:25 a.m., RN #5 stated s/he would immediately call the physician to clarify if the medication should be continued or discontinued.

e) During an interview, on 06/29/16 at 9:45 a.m., RN #6 stated it was the RN's responsibility to clarify incomplete medication orders with the physician.

f) During an interview, on 06/29/16 at 11:53 a.m., the Director in Inpatient Services (Director #4) stated it was clearly the responsibility of the RN to clarify an incomplete order with the physician. His/Her expectation was the RNs would call the physician and document the results of the clarification.

g) During an interview, on 06/29/16 at 12:22 p.m., the Director of Pharmacy (Director) #7 stated there should be follow-up with the physician to determine if the Zoloft medication listed in Patient #2's chart was needed or not. The order in Patient #2's chart was not complete. There was no documentation of contacting the physician to clarify the order.

h) During an interview, on 06/29/16 at 1:00 p.m., the Chief Nursing Officer (CNO) #2 stated the expectation was that the Zoloft on the Transfer Medication Summary and the Discharge Order Medication Profile should have been addressed and clarified by the RN.