HospitalInspections.org

Based on observations, staff interviews, medical record reviews, and policy/procedure review, the facility failed to ensure a complete and accurately documented medical record was maintained for one (1) of three (3) medical records reviewed; Patient #1.

Findings Include:

Medical record review for Patient #1 revealed the "Patient care/ADL's (activities of daily living)/Activities" had no documented evidence of bath performed and/or turning (repositioning of patient) for patient from 01/31/2022 - 02/08/2022.

During interview on 02/10/2022 at 11:15 a.m., Registered Nurse (RN) Director of Quality confirmed no evidence of documentation of bath performed and/or turning (repositioning patient) from 01/31/2022-02/08/2022 for Patient #1.

Review of facility's "Him.089 The Legal Medical Record;" policy, number 9017130 reveals: " ...Each Medical Record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers ...".

Review of facility's "Patient Assessment and Reassessment;" policy number 9267277, reveals: " ...that a multidisciplinary process be utilized for assessment and reassessment of patients. Patients are assessed by qualified individuals initially to determine each patient's need for care ...".

Review of facility's "Skin Assessment, Documentation, and Treatment, NS.S.001;" policy number 8699218, reveals: " ... Patient should be identified as high risk for skin breakdown on ... plan of care ... bathe patient daily with pH balanced liquid cleaner and water or with no rise bath cleansing wash-cloths ...".

During Exit conference on 02/10/2022 at 5:00 p.m., survey findings were discussed and no further documentation was submitted for review.

Based on staff interviews, observations and policy/procedure review, the facility failed to ensure operative call light system at bed side in one (1) of three (3) patients: Patient # 1

Findings Include:

Observation of Room #353 on 02/09/2022 at 11:40 a.m., revealed non-operative call light system or a hand call bell at patient's bedside.

During interview on 02/09/2022 at 11:45 a.m., Registered Nurse (RN) Director of Quality confirmed a non-working call light at patient's bedside in Room #353 and no other hand bell at bedside.

During interview on 02/09/2022 at 1:20 p.m., Administrator Director MSN, FNP confirms call lights at patient's bedside have been reported to maintenance and at least one component of the call system in Rooms #351-#361 did not work correctly.

During interview on 02/09/2022 at 2:10 p.m., Assistant of Plant Operation confirms a list of call lights (out of order) due to a short in the main electrical board that operates the system in the specific Room numbers 250-254 and Room numbers 353-361. Proposal made on 02/08/2021 for new call system was purchased but has not been installed as of 02/09/2022.

During interview on 02/10/2022 at 1:05 p.m., RN Team Leader confirms she did explain to patient the call light was not working at the beside but failed to place hand bell in room.

Review of the facility's "Emergency Communications, EC. 023;" policy number 10040870, revealed: " ...Nurse Call System: 1. In the event that there is a failure of the nurse call system ...3. Nursing assistants ...will be stationed at strategic points around the nursing units to relay patient request to the nurse's station... 4. Service bells are maintained in the nursing supervisor's office for use ...".

Review of the facility's "Patient Safety Program, PI. 003;" policy number 9685497, revealed: "1. It is the policy of Delta Health-The Medical Center, to utilize a proactive approach ... and patient safety is promoted ...2. All patient care staff shall use every reasonable precaution to provide a safe environment ...".

During Exit Conference on 02/10/2022 at 5:00 p.m., survey findings were discussed and no further documentation was submitted for review.