HospitalInspections.org

Based on interview and record review the facility's nursing administration failed to ensure organized nursing care when:
- Two (2) out of four (4) patients were not offered baths or linen changes while patients at the facility. (Patients #1 and #4) and
- failed to label and date when Intravenous (IV) tubing was hung and when IVs were inserted, to minimize the risk of infections. (Patients #2, 3 and 4)

Findings Include:

Review of a written complaint and a telephone interview on the morning of 2/12/18, Patient #1's wife stated, "There was no bathing, no changing linens..."

During an interview on the morning of 2/12/18, on the 4th floor inpatient unit, when asked how long the patient had been in the facility and if they had been offered to have the linens changed Patient #4 stated, "I've been here three days...they changed my bed pad but not the linens, they did not ask me if I wanted a shower, I asked them."

During an interview on the morning of 2/12/18, in the facility conference room, when asked how often the patients are bathed, Staff #7, Unit 4 Manager stated, "The practice is every twenty-four hours, it's not set in stone....we were going to change it to every other day, but we never decided...." Staff #7 confirmed the lack of documentation of the baths offered or the linens being changed.

During an interview on the morning of 2/12/18, in the facility conference room, when asked if the facility has a policy on patient baths and linen changes, Staff #4, Network Trainer stated, "I don't think so....I do the general orientation; they also have a site orientation."

During a telephone interview on the morning of 2/12/18, in the facility conference room with administrative personnel, Staff #6, Seton Northwest Trainer stated, "...we offer a bath every single day and change the linens every other day.... Ideally it should be document...they are taught on day one of the unit orientation."

During an interview on the morning of 2/12/18, on the facility's 4th floor inpatient nursing unit, Staff #5, Certified Nursing Assistant, when asked how often the patients are offered a bath stated, "We ask them every day...we document it in I View." When asked how often the linens are changed, Staff #5 stated, "We ask them every day, unless they are soiled then we change them as needed."

Review of the facility provided Certified Assistant job expectations (undated) reflected "The following items are requirements of your position.... Bath, oral care and bed changes offered every shift. Make beds as needed, even if you are not changing the linens.... "
Observations on the morning of 2/12/18, on the facility's medical surgical 4th floor unit revealed the following:

Patient #2 had IV fluids with no label or date of when the tubing had been hung. Patient #2's IV to his left arm did not have the date of insertion.
Patient #3 had an IV to his right arm did not have the date of insertion.
Patient #4 did not have IV fluids with no label or date of when the tubing had been hung.

During an interview on the morning of 2/12/18, on the facility's medical surgical 4th floor unit, Staff #7, Unit 4 Manager stated, "They don't have to be labeled, the information is documented in the computer...."

Review of the facility provided policy Intravenous (IV) Tubing (dated 9/2013) reflected, "..Primary tubing a. Tubing may be used up to 96 hours...Date the tubing with the day that the tubing is hung..."

Review of the facility provided policy Peripheral Intravenous Catheter - Inserting, Maintaining, and Discontinuing (dated 6/27/17) reflected, " ..Sites are rotated every 96 hours ..write the date and time on the label and place on the dressing...."