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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance.

A0398 - All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). Based on interviews and document review, the facility failed to perform patient services. Specifically, the facility failed to provide assistance required for activities of daily living (ADLs) in three of three medical records reviewed (patient #1, #2, and #3).

Based on interviews and document review, the facility failed to perform patient services. Specifically, the facility failed to provide assistance required for activities of daily living (ADLs) in three of three medical records reviewed (Patients #1, #2, and #3).

Findings include:

Facility documents:

According to a document provided by the facility titled Lippincott Procedures - Tub Baths and Showers, revised 5/19/22, tub baths and showers provide personal hygiene, stimulate circulation, and reduce tension for a patient. They also allow observation of the condition of a patient's skin and assessment of joint mobility and muscle strength. Documentation: Describe the patient's skin condition and record any discoloration or redness in your notes. Document the patient's tolerance of the procedure. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

According to a document provided by the facility titled Lippincott Procedures - Bed Bath, revised 5/19/22, performing a bed bath not only cleans a patient's skin but also stimulates circulation, provides mild exercise, and promotes comfort. It also enables assessment of the condition of the patient's skin as well as joint mobility and muscle strength. Document the procedure. Record the date and time of the bed bath. Note the patient's tolerance of the bed bath, range of motion, and self-care abilities, and document any unusual findings. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

1. The facility failed to ensure patients received a bath or shower in accordance with the facility's expectation.

a. Patient #1's medical record was reviewed. According to the History and Physical (H&P) dated 9/21/22, Patient #1 had a history of dementia (impaired ability to remember, think, or make decisions that interfere with conducting everyday activities), hearing loss, hypertension (increased blood pressure), and osteoarthritis (degenerative joint disease). On 9/19/22 Patient #1 had a cancerous mass removed from her right lower leg at an outpatient facility. On 9/21/22, Patient #1 had increasing weakness and decreased cognition and was admitted to the facility on 9/21/22 with the diagnosis of deep tissue surgical wound infection.

Patient #1's medical record revealed she was hospitalized for 23 days and only showed evidence of five bed baths on 9/22/22, 9/30/22, 10/4/22, 10/9/22 and 10/11/22. There was no further evidence noted in the medical record of Patient #1 receiving a bath or shower.

b. Patient #2's medical record was reviewed. According to the H&P dated 5/6/22, Patient #2 had a history of a venous embolism (a condition that occurs when a blood clot forms in a vein), blindness, arthritis, ovarian cancer and a right knee replacement. On 5/6/22, Patient #2 was admitted to the facility with a diagnosis of postoperative infection.

Further review of Patient #2's medical record revealed she was hospitalized for eight days with no evidence of a bed bath or shower received.

c. Patient #3's medical record was reviewed. According to the H&P dated 10/25/22, Patient #3 had a history of hereditary spastic paraparesis (progressive weakness and stiffness of the legs), depression, benign prostatic hyperplasia (prostate gland enlargement), hypertension, diabetes, chronic kidney disease, chronic pain syndrome (pain that lasts for over three months) and stroke. On 10/25/22, Patient #3 was admitted to the facility with a diagnosis of altered mental status and confusion.

Patient #3's medical record revealed he was hospitalized for 11 days and only showed evidence of one shower on 11/2/22. There was no further evidence of a bath or shower noted in the medical record.

d. On 12/6/22 an interview was conducted with certified nursing assistant (CNA) #3. CNA #3 stated it was her job, as well as the nurse's job, to ensure patients were bathed. CNA #3 stated patients were expected to be bathed two times a week. CNA #3 stated patient baths and showers were expected to be documented in the medical record, even if the patient did not need assistance. CNA #3 stated if a patient refused a bath or shower, the refusal was expected to be documented.

e. On 12/6/22 at 1:57 p.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated activities of daily living (ADL) included oral hygiene, face washing, hair brushing, and bed baths or showers. RN #2 stated nurses and CNAs were responsible for assisting with patients' ADLs and patients were offered baths daily. RN #2 stated staff made sure patients were bathed at least every other day. RN #2 stated baths were expected to be documented, even if the patient did not need assistance, in the patient's medical record. RN #2 stated patients had the right to refuse a bath or shower and the refusal was expected to be documented. RN #2 stated it was important for patients to be bathed because it was good for the patient to have clean skin which improved circulation. RN #2 stated there was an increased risk of bacteria being left on the skin which could cause an infection if bathing was not completed.

f. On 12/7/22 at 8:32 a.m., an interview was conducted with chief nursing officer (CNO) #1. CNO #1 stated RNs and CNAs were responsible for patient hygiene, which included providing bed baths and showers. CNO #1 stated the facility's expectation was that patients were to be bathed or showered every 24 hours. CNO #1 stated a patient had the right to refuse a bed bath or shower and staff were expected to document the refusal. CNO #1 stated the facility followed Lippincott procedures for patient bed baths and showers, and Lippincott's guidance was to document the bath or shower. CNO #1 stated bed baths and showers were important and there was a risk of infection if not performed.