HospitalInspections.org

Based on record review and interview the hospital failed to ensure wound care orders were obtained for one (Pt #1) of five patients.

Findings:

Pt #4
Reveiw of the medical record showed an inpatient stay 02/04/25 to 02/11/25. The patient was a 95 year old with diagnoses of Influenza, Catheter-associated urinary tract infection, Acute Kidney Injury and Chronic Kidney Disease. The patient weighed 117 pounds and had a height of 5'11". A review of nursing assessments, nurses notes, and physician orders showed no physician notification of the wound to the right heel. No verification of wound documentation was provided to the surveyor showing wound measurements.

On 06/03/25 at 10:50 am Staff M stated:
1. there was no documented physician notifiation of the right heel wound and
2. no orders were obtained for the wound.

Based on record review and interview, the hospital failed to ensure all necessary discharge instructions were included in the discharge paperwork for one (Pt #4) of five patients.

Findings:
Review of the policy titled " Discharge Planning" and approval date of 04/2025 read in part, "The patient and persons acting on his/her behalf are counseled by the interdisciplinary team to ensure that the patient/caregiver is:
a. Prepared for post-hospital care
b. Kept informed of the status or progress of the discharge plan including any financial liability
c. Able to verbalized and/or demonstrate the care needed by the patient."

Pt #4
Reveiw of the medical record showed an inpatient stay 02/04/25 to 02/11/25. Pt #4 had wounds (stage II pressure ulcer to coccyx and an area to the right heel that developed as a blister). The discharge information did not include where the wounds were located, what type of wounds were present, or wound care instructions. Documentation showed the patient lived with family.

On 06/03/25 at 10:50 am Staff M stated instructions regarding wounds (location, type, etc.) and wound care should be included in discharge instructions.

Based on record review and interview the hospital failed to ensure patient care services were provided in accordance with acceptable professional standards of practice for two (Pt #1 and 4) of five patients.

Findings:

Reveiw of "AACN Updates Bathing Practices Protocol" dated 04/18/13 showed, "Based on the latest available evidence, the expected practice related to bathing adult patients includes:
Provide a daily bath for bed-bound patients to improve hygiene and promote comfort. More frequent baths may be performed upon patient request or to respond to patient needs."

Review of "Bed Bath and Hygiene Care" (an education website geared towards helping student and registerd nurses) Updated on July 6, 2024 showed, "Bed bath and hygiene care are fundamental aspects of nursing, essential for maintaining patient health and comfort. These practices involve cleaning the patient ' s body when they are unable to bathe themselves due to illness, injury, or immobility. This care also offers an opportunity for nurses to assess the patient ' s skin condition, identifying any potential issues early. Ultimately, bed bath and hygiene care are crucial for preserving patient dignity and ensuring a high standard of health care."

Pt #1
Reveiw of the medical record showed an inpatient swing bed stay 03/21/25 to 03/27/25. Pt #1was an 82 year old with a diagnoisis of Physical Debility. A review of clinical documentation showed patient received a shower once 03/25/25 during the swing bed stay. No offer of a bath/shower or a refusal was documented for 03/21/25, 03/22/25, 03/23/25, 03/24/25, 03/26/25, or 03/27/25.

Pt #4
Reveiw of the medical record showed an inpatient stay 02/04/25 to 02/11/25. Pt #4 was a 95 year old with diagnoses of Influenza, Catheter-associated urinary tract infection, Acute Kidney Injury and Chronic Kidney Disease. The patient weighed 117 pounds and had a height of 5'11". A review of the clinical record showed not documentation that Pt #4 received a bath/shower or refused a bath/shower during the hospitalizaton.

Review of the document titled "Ambulance Transport Certificate of Medical Necessity" dated 02/11/25 showed "Pt is weak and bed bound at this time."

On 06/03/25 at 10:50 am Staff M stated:
1) my expectation would be that a bath/shower would be offered to patients and if refused staff should document the refusal;
2) Pt #1 had one shower during the admission 03/21/25 to 03/27/25;
3) Pt #4 had no bath or shower during the admission 02/04/25 to 02/11/25.