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Based on review of documentation and interview it was determined that the hospital failed to ensure that patient #1 had received bathing as frequently as required by the hospital's own policy related to pressure ulcer prevention and management.

Hospital policy (provided to the surveyor for review) entitled: "Pressure Ulcer Prevention and Management" with a revision date of 11/6/2016 stated on page 2 of 4: "b. Moderate to High Risk - Score or 14 or less on the Braden Scale." "iii Bathe daily with mild soap, rinse and dry thoroughly."

Review of "LG General Nursing Assessment" forms revealed the scoring system for the Braden Scale (note: the purpose of the Braden Scale is to help health professionals, assess a patient's risk of developing a pressure ulcer). The nursing assessment form stated: "*Braden Score Total Score of 17 or Greater Low Risk Score of 16 or Less Moderate to High Risk**Score of 16 or Less Puts Patient at Risk for Pressure Ulcer**".

Review of the "LG General Nursing Assessment" forms for patient #1 revealed that nursing staff had scored the Braden scale for patient #1 as 14 or less on:

09/15/2017 at 23:54 hours. Braden Scale score was listed as 14.0
09/16/2017 at 21:10 hours. Braden Scale score was listed as 13.0
09/17/2017 at 07:50 hours. Braden Scale score was listed as 14.0
09/17/2017 at 19:15 hours. Braden Scale score was listed as 14.0
09/18/2017 at 20:00hours. Braden Scale score was listed as 14.0
09/19/2017 at 21:30hours. Braden Scale score was listed as 14.0

Review of "Frequent Rounding Performed By PATIENT CARE TECH" dated 9/18/2017 at 16:24 hours stated: "PATIENT HYGIENE COMPLETED BED BATH FACE WASHED LINENS CHANGED." Other than this entry for 9/18/2017, no other documentation was found by or provided to the surveyor indicating that patient #1 had received a bath on the other dates listed above where the Braden scale was less 14 or less which is required by the hospital's own policy.

In an interview with staff member #1 on the morning of 4/16/2019 the above findings were confirmed.

Based on review of documentation and interview it was determined that the hospital failed to ensure that patient medical records were complete.

Findings were:
The medical record of patient #1 was incomplete to include:

Review of "Total Joint Intraoperative Medications Orders Set" dated 9/15/2017 at 0700 hours revealed the area where the Height and Weight of patient #1 were to be documented was blank.

Review of "Physician Orders Routine Recovery Orders for Anesthesia" dated 9/15/2017 at 1830 hours (time and date by nursing signature) revealed the area at the top of the page where the date and time were to be entered was blank. The area where the Height and Weight of patient #1 was to be documented was blank. The area where vital signs were to be documented was blank. The area to the right of where the Anesthesia Provider signed their name had an area where the date and time was to be documented, this area was blank with no date or time.

Review of the "Intra-operative Care Plan" revealed that the area stating: "Counts correct, the patient's wound was closed with all sharps, instrument parts and other foreign objects accounted for" had an area where an individual was to put their signature. This area was blank with no signature.

Review of the "Patient Nursing Pre-Operative Assessment" dated 9/15/17 at 1330 hours revealed on page the area where "GI" (gastrointestinal) was assessed had boxes which could be checked, the choices were: "soft, distended, tender, location." None of the choices had been checked nor was there any comment in the "other section." The area directly below documented assessment of "Bowel sounds." The choices in this area were also boxes which could be checked. The choices were: "present, absent, nausea, vomiting." None of these choices had been selected.

Review of "Anatomical - Wound Assessment 1" dated 09/18/2017 at 20:00 hours was incomplete as it had not been electronically signed by the nurse conducting the assessment. The anatomical assessment showed both an area with a yellow circle on the lower back of the anatomical figure and a pink colored triangle on the front of the left knee. The area on the first page where the nurse's signature would appear if the assessment had been completed was blank. It was confirmed with staff member #3 in an interview on the afternoon of 4/15/2019 that this assessment was incomplete as it did not have the name of the name of the nurse who had completed it.

Hospital policy entitled: "Content of the Medical Record" stated under the procedure section: "A. All medical record entries, including handwritten and electronic, must be legible, complete, true and accurate, dated and timed and authenticated by the person responsible for providing or evaluating the services provided consistent with hospital policies." "L. Clinical Entries- a.) All clinical entries in the patient's medical record will be accurately dated, timed and authenticated."

Hospital policy entitled: "Legal Health Record" stated on page 6 of 10: "3. Authentication of the LHR." "Consistent with Medical Staff Rules and Regulations, Medical Staff Bylaws, federal and state law, and policies and procedures, if applicable, all entries in the LHR will be dated, timed and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided."

Hospital policy entitled: "Health Record Signature/Electronic Signature Requirements" stated under the Procedure section: "All entries into the medical record must be authenticated by their author, dated and timed. Providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering service."

In an interview with staff members #1, #2, and #3 on the afternoon of 4/15/2019 the above findings were confirmed.

Based on review of documentation and interview it was determined that nursing staff failed to carry out physician orders.

Findings were:
Nursing staff failed to carry out physician orders.

Review of electronic physician order dated 9/20/2019 at 0741 hours stated: "Change Dressing Before Discharge." This order was authenticated by the ordering physician on 9/20/2017 at 0742 hours. The area below where nursing staff are to acknowledge the order was blank. Patient #1 was discharged on 9/20/2017 at approximately 12:40 hours.

Review of "Frequent Rounding Performed By Nurse" documentation dated 9/20/2017 at 0900 hours which was completed by staff member #7 stated under the Additional Care Provided Section: "Patient's brief was changed, dressing was reinforced with ADB pad and tape, patient repositioned for comfort." No other documentation was found by or provided to the surveyor to document that the nurse (staff #7) had changed the dressing per the physician order.

Review of the "Lake Granbury Medical Center Position Description/Competency Based Evaluation Registered Nurse - Medical/Surgical Unit 3" stated on page three under the "Essential Functions (Part 1): "Certifies that physician orders are transcribed, clarified if necessary, and carries out correctly in a timely manner."

In an interview with staff members #1, #2, and #3 on the afternoon of 4/15/2019 the above findings were confirmed.