HospitalInspections.org

Based on staff interview and document review, it was determined the facility failed to ensure all nursing staff who provide services in the hospital followed the policies and procedures of the hospital. Specifically, hospital nursing staff failed to document providing a bath/hygiene to one (1) of five (5) patients reviewed in the survey sample. Medical record #1.

Findings:

The medical record for patient #1 failed to contain documentation that the patient was bathed 04/28/23 and 04/29/03. The surveyor requested to speak to the Registered Nurse (RN) assigned to the patient these days. The facility reported the RN was a contract nurse and was no longer at the facility. The surveyor requested to speak to the nursing tech assigned to the patient these days. The tech only worked Saturdays and was unavailable for interview.

The surveyor requested the facility's policy/procedure for bathing and hygiene care. Per staff member #2, the facility does not have such a policy and bathing is based on unit standards.

An interview was conducted on 05/11/23 with the nurse manager of the medical surgical floor the patient was on. The nurse manager stated that the expectation for hygiene was for patients to be bathed daily and as needed. Information related to bathing should be documented in the medical record. The nurse manager confirmed documentation of bathing patient #1 on the above noted dates was not present in the medical record.

An interview was conducted with the RN assigned to the patient on 05/11/23. The RN stated that patients should be bathed daily and as needed and this information would be documented in the medical record. Bathing is a shared responsibility between nurses and nursing technicians. A nurse would review the medical record to know if the patient had been bathed already that day or still needed a bath. The RN stated patient #1 had received a bath today (5/11/23) and the nurse and tech had provided incontinence care and turning to the patient 05/11/23.

The above noted deficiency was reviewed with leadership staff during the exit conference on 05/11/23.