HospitalInspections.org

Based on record reviews and interviews, the facility Governing Body failed to insure that nursing staff followed the facility's own policies and procedures to document accurate assessments and events in the medical record. This facility staff failed to follow policy.

Findings:

Facility Policy "Title: MS-027 Personal Hygiene for Patients
PROCEDURE
Patients are given and/or offered routine oral and personal hygiene. (Refer to Lippincott for
additional details.) Patients should be bathed or given an opportunity to bathe daily and more
often if necessary. Patients should be given assistance to clean their teeth or dentures in the
morning, preferably before breakfast and at night. Patients in ICU have a more rigorous oral care
program that corresponds with the Ventilator Acquired Pneumonia (VAP) Bundle recommendations."

Facility Policy "Title: Pressure Injury Prevention, Minimization & Identification - NS
PRESSURE INJURY PREVENTION MEASURES
1. MILD RISK - BRADEN SCORE OF 18 OR LESS:
a) Frequent turning and repositioning as appropriate. If unable to turn independently, initiate
a regular turning schedule with a minimum of every two hours and PRN, minimum of every hour turns
and PRN while in chair."

Review of the medical record for patient #1 revealed the facility's Daily Nursing Assessment, performed every 12 hours
reflected no documentation for oral care on the following days:

03/01/24 No documented of oral care provided.
03/02/24 No documented of oral care provided.
03/03/24 No documented of oral care provided.

A review of the medical record for patient #1 during admit 3/1/24 to 3/4/24 revealed the facility's Daily Nursing Assessment, performed every 12 hours did not reposition every two hours per facility policy.

During an interview with Staff #3 on 3/18/24 the above findings were confirmed. The staff failed to document oral hygiene and repositioning of pt every two hours.