HospitalInspections.org

Based on a review of medical records, facility policy and procedures, staff and patient interviews, and observations, it was determined that the facility failed to ensure that nursing services assessed and documented activities of daily living (ADL) for three patients (P) (P#1, P#2, and P#3) of four sampled medical records. Specifically, nursing staff failed to ensure oral care was provided or documented for patients that require ADL assistance.


Findings included:


1. A review of P#1's medical record revealed that P#1 was admitted to the facility on 3/2/25.


A review of "General Surgery Note" dated 3/3/25, revealed that P#1 is fairly independent at home. She uses a cane and occasionally requires assistance from her husband or daughter for activities of daily living (ADL) care (basic self-care tasks individuals perform daily to maintain independence).


A review of "Order," dated 3/5/25, revealed that an order for Occupational Therapy (OT) was placed due to P#1's impaired activities of daily living (ADL) functionality.


A review of the "Physical Therapy Initial Assessment," dated 3/6/25, revealed that P#1 was independent with ADL care at home before admission. During admission, P#1 required using a PureWick (female external catheter that wicks urine away using low pressure suction) and maximum assistance with a bedside commode, with perineal hygiene assistance post-bowel movement.


Further review failed to reveal documentation that P#1 received daily ADL oral care from 3/2/25 through 3/8/25.


2. A review of P#2's medical record revealed that P#3 was admitted to the facility on 3/4/25.

A review of "Physical Therapy Initial Assessment," dated 3/10/25, revealed that ADL care required maximum assistance.


Further review failed to reveal documentation that P#3 received daily ADL oral care on 3/5/25, 3/6/25, 3/7/25, 3/9/25, 3/12/25, and 3/14/25.


3. A review of P#3's medical record revealed that P#3 was transferred and admitted to the facility on 4/23/25.


A review of "Orders," dated 4/23/25 at 2:56 a.m., revealed that an active order for oral care was placed.


Further review failed to reveal documentation that P#3 received daily ADL oral care from 4/23/25 through 4/29/25.


Observation of P#3 on 4/29/25 at 8:40 a.m., revealed patients teeth with a film and buildup, long fingernails with dark brown matter caked underneath them, and white crust around his eyes and nose.


Observation of P#3's room revealed a bedside table that was out of P#3's reach. Further observation of the bathroom failed to demonstrate oral hygiene care supplies. P#3 at this time requested to have his teeth brushed.
Observed a Care Partner (CP) bring two toothbrushes and two toothpaste tubes into P#3's room. This surveyor stepped out of the room to allow P#3 privacy. Nurse Manager (NM) AA was present at this time and explained that P#3 had been provided oral care, but that staff failed to document it in the medical record.


Observation of P#3 on 4/30/24 at 9:30 a.m. with NM AA revealed the same unopened two toothbrushes and toothpaste tubes in the bathroom. When the NM AA was asked to explain why these supplies were unused after P#3 requested oral care on 4/29/25, she explained that P#3 had not had his teeth brushed in such a long time that staff chose to throw the toothbrush and toothpaste away after the first use and the supplies in the bathroom were new. She continued to explain that he is a confused patient. When this surveyor asked NM AA what P#3's neurological assessment was for that day, she explained that it had not been completed then and that his nightshift neurological assessment revealed that P#3 was within normal limits.
Further observation of P#3's room revealed a strong urine odor. It was also revealed that P#3's gown and linen were urine-saturated.


A review of the facility's policy titled "PS-51 Nursing Plan of Care," policy # PS-51, last revised 6/16/23, revealed that the policy was to provide safe, effective Nursing care to all patients.
PROCEDURE:
NOTE: The POC is individualized to meet patient needs based on data collected from nursing assessment and includes involvement of the patient, family, and/or significant other. Care planning, treatment, and services are collaborative and interdisciplinary.
Initiation of Care:
o Step One:
" Assess patients on admission and select/initiate POC based on appropriate diagnoses
" 1.2 Establish patient goals
Implementation:
o Step Two:
" 2.1 Document interventions implemented to meet individualized patient needs
" 2.2 Reassess patients at specified times based on the level of care or when there is a significant change in patient condition
Evaluation:
o Step Three:
" 3.1 Revise and reprioritize POC based on assessment or change in patient condition and diagnosis
" 3.3 Continue, revise, or resolve POC interventions to achieve established goals
A review of the facility's "Skills: Activities of Daily Living (ADL): Adaptive Equipment for Personal Hygiene (Rehabilitation Nursing) - CE/NCPD," dated 9/17/24, revealed;
13. Integrate the therapist's recommendations and plan of care.
16. Complete grooming tasks with the patient, assisting as needed.


During an interview on 4/29/25 at 12:26 p.m., with P#3 in a patient room, P#3 explained that he had been admitted for approximately a week for a wound on his left foot. He had previously had his right leg amputated due to it becoming gangrenous and is unable to ambulate due to the painful sores that have developed on his left foot.

P#3 expressed frustration that he had not washed his face for a week. He said that the staff would come in to clean his body but never wash his face or brush his teeth. When asked if he had been provided a toothbrush and toothpaste, he explained that no one had ever brought him toothpaste or a toothbrush, much less offered to brush his teeth, and it would make him feel better to have his teeth brushed.

P#3 said that staff do not ensure he can reach his water or juice because they position the bedside table in a manner that makes it difficult for him to get his drinks. P#1 added that he is unable to walk due to his amputation and the sore on his left foot; therefore, he has a condom catheter in place for when he needs to urinate and when he has a bowel movement he goes on the pads underneath him due to his inability to leverage the weight of his body upward to sit on a bedpan. He added that sometimes the condom catheter fails, and urine will saturate the pads and linen in the bed. He continued explaining that when he calls out for assistance, staff will come in and tell him they will be back shortly to change his bedding and clean him up, and they do not return for sometimes an hour or longer.


During an interview on 4/29/25 at 12:55 p.m. with P#6 in a patient room, P#6 stated that he had been admitted for a couple of weeks due to pneumonia and was waiting to secure a full-time home health aide that could assist him with daily living before he could be discharged.

P#6 explained that he was bedbound, unable to get to the bathroom, and required assistance for all his hygiene care. He said that overall, the staff has been responsive to his calls when he experiences incontinence and grooming needs. He said the night shift is slower to respond, but he did not feel he was left wet or dirty for an extended time.
He added that the staff would comply if asked to brush his teeth, but he could not recall when he last had oral care.


A follow-up interview was conducted on 4/30/25 at 8:30 a.m. with P#3 in a patient room. P#3 was asked if he was provided oral care. P#3 explained that the staff brought supplies but never assisted him with brushing his teeth. He added that in addition to not getting to brush his teeth, they had not come to clean him up since he had called out before the sun came up to alert staff that the condom catheter was not working, and urine had soaked onto him and the bedding and at 9:30 he still and not been cleaned up.

He continued to say that they brought his food in and placed it on the bedside table, which he could not reach.
P#3 expressed that he was frustrated because he felt as if staff only cared about getting vital signs done and not about providing him with assisted care.


A telephone interview was conducted on 4/30/25 at 9:17 a.m. with Licensed Practical Nurse (LPN) EE. LPN EE explained that she could not recall P#1 because she filled in briefly when P#1 was admitted there.

LPN EE stated that nurses and care partners (patient care technicians) are responsible for providing patients with activities of daily living (ADL) care. She said that whoever performs the care documents it in the patient's medical record, but the nurses oversee the care partners' patient care.

LPN EE explained that after she receives report during shift change, she will notify the care partner if a patient needs ADL care, especially for non-ambulatory patients, and most times is present in the room when the CP is bathing and changing the patient's linens because it allows her an opportunity to conduct a thorough skin assessment and address any patient concerns. She said she will document the ADL care at that time, and then throughout the shift, she will confirm patient ADL care is being provided by speaking with the care partner and confirming with the patient directly, and then she will double-check the medical record to ensure it was documented. She added that patient hygiene, including oral care, should be provided to patients every shift.


During an interview on 4/30/25 at 9:49 a.m. with Care Partner (CP) FF in a conference room, CP FF explained that her duties include providing patients with hygiene such as bathing, brushing teeth, and cleaning fingernails. Additionally, she assists with turning, feeding, changing, and providing patients with nutrition.

CP FF explained that she has been assigned to P#3 several times since his admission. She explained that he is sometimes confused, alert, and oriented. She said that P#3 is capable of brushing his teeth independently. She added that she keeps a toothbrush and toothpaste on his bedside table so that he can brush his teeth at his discretion, but often he does not, and that she forgot to document during the times that he did. She added that when she does anything for a patient, she is required to document it.

CP FF said that CPs are responsible for documenting the ADL care they provide, but it is supposed to be a shared responsibility between the CPs and the nurses to document it.


A telephone interview was conducted on 4/30/25 at 10:09 a.m. with Registered Nurse (RN) CC. RN CC recalled caring for P#1 because his Nurse Manager had notified him that P#1's husband had called the facility and made a violent threat against him. RN CC explained that P#1 had been on the unit for a few days before he was assigned to her, and he had her for two nights.

RN CC said he could not explain why oral hygiene care had not been documented for P#1, but didn't believe she had never received it because she was alert and oriented and could brush her teeth. He continued to explain that ADL care is the responsibility of the CP and that they are expected to document it anytime they perform it.

RN CC said that nurses provide oversight of the CPs they have delegated responsibility to and should review their documentation periodically throughout the shift. Additionally, nurses should assess and follow up with the patient to ensure they have been receiving ADL care delegated to the CP.


A telephone interview was conducted on 4/30/25 at 10:39 a.m. with Care Partner (CP) HH. CP HH explained that her duties include taking patient vital signs, providing ADL care, feeding, housekeeping as needed, and any additional patient needs.

CP HH explained that she can be assigned 10 to 11 patients each shift. She begins her shift by taking report and going room by room to greet each patient. She said hygiene should be provided every shift and as needed, including linen changes, peri care, foley care, Purewick change, oral care, and bathing.

CP HH stated that hygiene is very important because patients are human beings and should be provided the same care that we provide ourselves. She added that she must document every time she gives hygiene care, but sometimes she does not because she has to document every two hours anyway, so she will wait to do it then.

CP HH recalled caring for P#3 because she recalled he was a diabetic and had an amputated leg. She said that he is occasionally confused but is alert and oriented overall. CP HH explained that he can brush his teeth and that she would offer him opportunities to brush his teeth because he cannot ambulate to the bathroom, but she failed to document it. She added that when she changes his linen, she always does an oral swab and applies ointment to his lip but failed to document those occurrences as well.


During an interview on 4/30/25 at 11:18 a.m. with the Director of Nursing (DON) GG in a conference room, DON GG explained that the nurses oversee CPs and delegate specific nursing tasks to them based on what is within the CPs' scope of practice. The RN ensures the delegated tasks are performed and documented appropriately.
She added that she expects ADL care to be provided to every patient, every shift, and as needed. DON GG said that the charge nurses conduct weekly audits of medical records and review ADL care to ensure it is being provided and documented. Prior to the survey, she would have been surprised if medical records were missing documented ADL care.

DON GG stated that she expects the primary nurse to ensure that their patients receive ADL care, and that it's documented in the medical record. Still, the unit leader and she are responsible for providing nursing oversight to ensure patients receive appropriate care.


During an interview on 4/30/25 at 11:35 a.m. with the Chief Nursing Officer (CNO) II. CNO II explained that during this survey, they have identified opportunities to improve documentation. She acknowledged that if something was not documented in the medical record, it did not occur.

She continued to explain that CPs are under the nurses' supervision. She expects nursing staff to review their patients' medical records by the end of every shift and validate that ADL care has been provided and documented.
CNO II acknowledged that the Nurse Managers, the executive DONs, and she share accountability for nursing services.