HospitalInspections.org

Based on a review of documentation, and an interview with staff, the facility failed to ensure that the exercise of patients' rights requirements are met.

Findings were:

Review of the clinical record for patient #1 revealed that the patient was at Hillcrest Baptist Medical Center from 7-25-15 to 7-27-15 but was not offered a bath, a gown change or a linen change until 7-27-15.
3 additional observation patients (patients #2 - #4) also did not have documentation of basic hygiene offered.


In an interview with staff #5 on 10-7-15 at 03:30 PM, she was asked how often baths are offered to 6 south patients. "It should be the same across the continuum. The expectation is that a patent is offered a bath daily." She was asked how often linen is changed. She replied, "It should be offered daily, unless the patient refuses."
Facility policy BSWH.CLNETH.001.P titled "Patient Rights and Responsibilities" states, in part:
"The rights and responsibilities recognized at BSWH are as follows:
...
· We will treat all with dignity, compassion and respect for personal values, including spiritual beliefs."

Facility document titled "Patient Rights and Responsibilities" states, in part:
"Patients, or patients' legally designated representative if and when applicable, have a right to:
...
· Be treated with dignity, courtesy, consideration and respect."

The above was confirmed in an interview with the Director of Quality and Education, Assistant Chief Nursing Officer, Chief Medical Officer, Regulatory Services Coordinator, Director of Case Management and Risk Manager on the afternoon of 10-7-15.

Based on a review of documentation and an interview with staff, the nursing service did not have adequate numbers of RNs, LVNs and other personnel to provide nursing care to all patients as needed.

Findings were:

Review of the facility staffing grid and census for 7/25/15 through 7/27/15 revealed the following:
· 7-26-15 (7a-7p shift) - Census of 22, which should have been staffed with 5 RNs, 1 LVN, 2 Unit Aids and 1 Unit Secretary. Actual staffing reflected only 1 Unit Aid and no LVN.
· 7-26-15 (7p-7a shift) - Same census and shortages as listed above.
· 7-27-15 (7a-7p shift) - Census of 24, which should have been staffed with 6 RNs, 1 LVN, 2 Unit Aids and 1 Unit Secretary. Actual staffing reflected no LVN and no Unit Secretary.
In an interview with staff #8 on 10-7-15, staff #8 confirmed that the above three shifts were missing the listed personnel.

The above was confirmed in an interview with the Director of Quality and Education, Assistant Chief Nursing Officer, Chief Medical Officer, Regulatory Services Coordinator, Director of Case Management and Risk Manager on the afternoon of 10-7-15.

Based on a review of documentation, and an interview with staff, the facility failed to ensure that the exercise of patients' rights requirements are met.

Findings were:

Review of the clinical record for patient #1 revealed that the patient was at Hillcrest Baptist Medical Center from 7-25-15 to 7-27-15 but was not offered a bath, a gown change or a linen change until 7-27-15.
3 additional observation patients (patients #2 - #4) also did not have documentation of basic hygiene offered.


In an interview with staff #5 on 10-7-15 at 03:30 PM, she was asked how often baths are offered to 6 south patients. "It should be the same across the continuum. The expectation is that a patent is offered a bath daily." She was asked how often linen is changed. She replied, "It should be offered daily, unless the patient refuses."
Facility policy BSWH.CLNETH.001.P titled "Patient Rights and Responsibilities" states, in part:
"The rights and responsibilities recognized at BSWH are as follows:
...
· We will treat all with dignity, compassion and respect for personal values, including spiritual beliefs."

Facility document titled "Patient Rights and Responsibilities" states, in part:
"Patients, or patients' legally designated representative if and when applicable, have a right to:
...
· Be treated with dignity, courtesy, consideration and respect."

The above was confirmed in an interview with the Director of Quality and Education, Assistant Chief Nursing Officer, Chief Medical Officer, Regulatory Services Coordinator, Director of Case Management and Risk Manager on the afternoon of 10-7-15.

Based on a review of documentation and an interview with staff, the nursing service did not have adequate numbers of RNs, LVNs and other personnel to provide nursing care to all patients as needed.

Findings were:

Review of the facility staffing grid and census for 7/25/15 through 7/27/15 revealed the following:
· 7-26-15 (7a-7p shift) - Census of 22, which should have been staffed with 5 RNs, 1 LVN, 2 Unit Aids and 1 Unit Secretary. Actual staffing reflected only 1 Unit Aid and no LVN.
· 7-26-15 (7p-7a shift) - Same census and shortages as listed above.
· 7-27-15 (7a-7p shift) - Census of 24, which should have been staffed with 6 RNs, 1 LVN, 2 Unit Aids and 1 Unit Secretary. Actual staffing reflected no LVN and no Unit Secretary.
In an interview with staff #8 on 10-7-15, staff #8 confirmed that the above three shifts were missing the listed personnel.

The above was confirmed in an interview with the Director of Quality and Education, Assistant Chief Nursing Officer, Chief Medical Officer, Regulatory Services Coordinator, Director of Case Management and Risk Manager on the afternoon of 10-7-15.