HospitalInspections.org

Based on medical record review, staff interview and review of facility policy and procedures it was determined the registered nurse failed to supervise and evaluate nursing care related to personal care needs and implementation of physician orders for five (#3, #5, #7, #8, #9) of eleven records reviewed. This does not ensure the needs and goals of the patients are met.

Findings include:

1. Patient #3 was admitted to the facility on 9/25/2012 and discharged on 2/7/13. Documentation revealed the patient required total assistance with all ADLs (Activities of Daily Living). The record was reviewed for documentation of ADL care including hair care, oral care, peri care and bathing. Review of the documentation of hair care provided to the patient revealed that up to 4 days would pass with no hair care provided. Review of documentation from 1/18/13 to 2/7/13 revealed hair care was provided on 1/20, 1/22, 1/24, 1/28 and 2/3/13. Review of the documentation of oral care provided to the patient revealed that up to 3 days would pass with no oral care provided. Review of documentation from 1/18/13 to 2/7/13 revealed oral care was not provided on 1/21, 1/23, 1/26, 1/27, 1/29, 1/30, 1/31 and 2/3/13 to 2/7/13. On 2/1 and 2/2/13 the documentation indicated the patient was independent in oral care. Review of the record revealed the patient was incontinent throughout her stay at the facility. Documentation revealed the patient would have bowel movements and urine incontinence multiple times a day. Review of the documentation of bathing revealed that up to 3 days would pass with no documentation of bathing provided. Review of documentation from 1/18/13 to 2/7/13 revealed bathing was not provided on 1/25, 1/26, 1/28, 1/29, 1/31, 2/1, 2/2 and 2/7/13. Documentation of peri care provided to the patient revealed that up to 3 days would pass with no documentation that peri care was provided. Review of documentation from 1/18/13 to 2/7/13 revealed peri care was not provided on 1/27, 1/30, 2/1, 2/6 and 2/7/13. On 1/26/13 and 2/2/13 the documentation revealed the patient was independent in peri care.

Interview with staff members on 2/13/2013 at approximately 1:15 p.m., who cared for the patient during her stay, stated the patient required total assistance and oral care, hair care and bathing were provided on a daily basis. Review of the record revealed lack of documentation confirming ADL care of the patient.

On several days documentation by patient care technicians revealed the patient was independent with oral care and peri care. Interview with staff members on 2/13/2013 at approximately 1:15 p.m., on the same unit the patient was admitted, revealed patient #3 required total care, was demented and non-verbal.

Interview with the director of patient care services confirmed the above findings.

Review of the facility policy, "Documentation: Nursing", last revised 10/2012, states interventions for hygiene will be documented every shift or as indicated by patient condition.

Review of physician's admitting orders dated 9/25/2013 at 8:40 p.m. revealed an order to weigh the patient on admission and every Sunday, Wednesday, and Friday in the morning. Review of the record revealed the patient was weighed on admission and weighed 117 lbs. (pounds). Review of the record revealed no documentation the patient was weighed again or attempted to be weighed until 10/31/2012, approximately 30 days later. Review of the record revealed on 10/31/2012 nursing documented the patient would not cooperate to be weighed and no weight was recorded. On 11/11/2012 documentation revealed the patient was weighed and was 119 lbs. On 11/16/2012 the patient was attempted to be weighed. Nursing documentation revealed the patient would not cooperate. Review of the record revealed no other weight was recorded for the patient. The patient was discharged from the facility on 2/7/2013.

2. Patient #5 was admitted to the facility on 2/6/2013. Documentation revealed the patient was severely cognitively impaired and required maximum assistance with ADL care.

Review of the Activity of Daily Living (ADL) notes dated 2/12/13 at 8:55 p.m. and signed by the Mental Health Tech (MHT #1) documented the patient refused assistance with feeding and was independent with her oral care and personal hygiene.

An interview was conducted with the RN (Registered Nurse) on 2/13/13 at approximately 1:30 p.m. She stated Patient #5 was not aware of her surroundings, was incapable of providing her own care, and required maximum assistance with all of her activities of daily living.

The Director of Patient Services was present at the time of the record review and interview and confirmed the findings.

3. Patient #7 was admitted to the facility on 2/6/2013. Review of the ADL notes, dated 12/11/13 at 10:44 p.m. and signed by MHT #2 indicated the patient required moderate assistance with feeding, maximum assistance with activities and maximum assistance with personal hygiene care.

Review of the ADL notes dated 12/12/13 at 5:56 p.m. and signed by MHT #3, indicated the patient was independent in her activity, was independent in feeding, and was given hair care by the MHT.

Review of the ADL notes dated 12/12/13 at 8:45 p.m. and signed by MHT #1, indicated the patient was independent in activities, independent with her oral care and personal hygiene care.

An interview was conducted with the RN on 2/13/13 at approximately 1:30 P.m. She stated Patient #7 required assistance with all activities and was not capable of providing her own care.

The Director of Patient Services was present at the time of the record review and interview and confirmed the findings.

4. Patient #8 was admitted to the facility on 2/2/2013. Review of the ADL notes dated 2/12/13 at 5:14 p.m. and signed by MHT #4 indicated the patient required maximum assistance with activity, moderate assistance with feeding, moderate assistance with foot, hair, oral, and personal hygiene care.

The ADL notes, dated 2/12/13 at 8:42 p.m. and signed by MHT #1, documented the patient required maximum assistance with activity, refused feeding assistance and was independent in her oral and personal hygiene care.

An interview was conducted with the RN on 2/13/13 at approximately 1:30 p.m. She stated Patient #8 required assistance with all activities and was not capable of providing her own care without assistance.

The Director of Patient Services was present at the time of the record review and interview and confirmed the findings.

5. Patient #9 was admitted to the facility on 1/29/2013. Review of the ADL notes dated 2/12/13 at 5:03 p.m. and signed by MHT #4 indicated the patient required maximum assistance with activity, had refused feeding assistance and required maximum assistance with foot, hair, oral, and personal hygiene care.

Review of the ADL notes dated 2/12/13 at 8:37 p.m. and signed by MHT #1 indicated Patient #9 was independent in her oral and personal hygiene care.

An interview was conducted with the RN on 2/13/13 at approximately 1:30 p.m. She stated Patient #9 required assistance with all activities and was not capable of providing her own care without assistance.

The Director of Patient Services was present at the time of the record review and interview and confirmed the findings.