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Based on staff interview, medical record review and policy and procedure review, the facility failed to provide care in accordance with the patient's needs for one (1) of three (3) medical records reviewed on two (2) of two (2) days of survey; Patient #1.

Findings Include:

Interview with Registered Nurse (RN) #1 on 01/12/2023 at 10:15 a.m. confirmed she offered a bath close to end of shift, but patient started shaking legs and talking out loudly and was not able assist with bath.

Interview with RN #2 on 01/12/2023 at 10:35 a.m. confirmed the sister of the patient did ask for assistance with a bath and RN #2 told her that she had to make rounds and then would return to assist. RN #2 confirmed she did not assist with a bath the remainder of her shift due to patient was sleeping.

Interview with Director of Nursing (DON) on 01/12/2023 at 2:00 p.m. confirms no documented evidence of staff assistance with a bath during hospital stay from 11/06/2022-11/08/2023.

Review of the medical recorded titled, "Progress Notes", for Patient #1, revealed: " ...dates 11/06/2022, 11/07/2023 and 11/08/2023 showed no documented evidence of assistance of bath during hospital admission through discharge.

Review of the facility's policy # NURS 0014 "Scope of Care" reviewed date of 08/30/2018, revealed: "The nursing department offers services 24 hours a day, seven days a week to inpatients ...These services include a wide-range of care and treatments ...The Department of Nursing ...in place to deliver quality patient care ....uses the nursing process to design and provide nursing care to meet the individual needs of patient requirements and priorities for care, and match those requirements with the knowledge and skills of the nursing staff."

Review of the facility's policy #NURS 0016 "Organizational Plan: Authority-Responsibility-Accountability" reviewed date 08/30/2018, revealed: "The Nurse Manager is responsible and accountable for the 24-hour operation of an assigned unit. He/she is responsible for all provisions of patient care including the nursing process ...The Nurse Manager is responsible for the scheduling and staffing to ensure availability of staff to meet the needs of all patients."

During exit conference on 01/12/2023 at 2:30 p.m., survey findings were discussed and no further documentation was submitted for review.