HospitalInspections.org

Based on document review and staff interview, it was determined for 3 of 4 (Pts #1,2 and 3) clinical records reviewed for patients on mechanical ventilation, the hospital failed to ensure oral care was completed in accordance with hospital policy.

Findings include:

1. The hospital's policy entitled "Infection Control: Oral Care for Ventilated Patients" (effective 8/2012) was reviewed on 9/17/14 at approximately 1:00 pm and required, "...1. The oral cavity is assessed every shift and PRN [as needed] by the registered nurse. 2. Intubated patients are provided oral care using a swab and cleansing agent every four hours and PRN. 3. Brushing of teeth and/or oral cavity, including tongue, with a soft suction toothbrush and subglottic suctioning will be performed twice a day and PRN by the nurse or respiratory therapist ...Use chlorhexidine mouth rinse for oral decontamination twice a day ...Document oral care every four hours in EPIC under Hygiene/ Skin Care ... "

2. The clinical record for Pt #1 was reviewed on 9/17/14 at approximately 10:00 am. Pt #1 was a 72 year old male who was admitted to the hospital's ICU (intensive care unit) on 7/28/14 with a diagnoses of cardiac arrest, anoxic brain damage, chronic encephalopathy, hypertension, congestive heart failure, and respiratory failure. Pt #1 had a chronic tracheostomy and was on chronic ventilator support. Nurses ' notes lacked the completion of oral care (teeth brushed and mouth swabbed with Chlorhexidine) on 7/29/14 between 12:03 am and 8:00 am (approximately 8 hours) and between 8:00 am and 11:00 pm (approximately 15 hours).

3. Pt #2 was a 32 year old male admitted to the hospital on 9/7/14 with diagnoses of pneumonia and hypoxia. The clinical record lacked documentation of completion of oral care on 9/14/14 between 8:00 am and 8:00 pm (12 hours).

4. Pt #3 was a 75 year old female admitted to the hospital ' s ICU on 9/9/14 with a diagnosis of respiratory failure. The clinical record for Pt #3 lacked documentation of completion of oral care on 9/15/14 between 9:00 am and 4:00 pm (7 hours).

5. On 9/18/14 at approximately 1:00 pm, the Director of Nursing stated that oral care should have been completed every 4 hours.