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Based on review of documents and interview of staff, it was determined the facility failed to ensure nursing staff completed and documented daily bathing and linen changes for five (5) of ten (10) medical records reviewed (Patients # 1, #2, #4, #8, and # 10). This failure can lead to incomplete and/or inadequate care of all patients' hygiene needs, with potential negative outcomes.

Findings include:

1. An interview was conducted with the Interim Nurse Manager, Fourth (4th) Floor Pavilion Unit (4P unit) on 3/7/16 at 11:45 a.m. She reported there is no facility policy stipulating the frequency of patient baths and linen changes, but stated the unit expectation is at least daily, and also as needed for patient comfort for both tasks. Six (6) random licensed staff members interviewed during the survey (RNs # 1, 2, 3 and 4, and LPN's #1 and 2) stated their awareness of this expectation.

2. A review of Patient #1's medical record was conducted on 3/7/16 and revealed an admission date of 1/7/16 and discharge date of 1/27/16. The record contained no bath documented as given or offered for the dates 1/8/16, 1/9/16, 1/12/16, 1/13/16, or 1/21/16. The record revealed no linen change was documented for 1/8/16, 1/9/16, 1/12/16, 1/16/16, 1/17/16, 1/18/16, 1/21/16, 1/22/16, 1/23/16, 1/24/16, or 1/25/16.

3. A review of current Patient #2's medical record, admission date 3/6/16, was conducted on 3/8/16, and revealed no documentation of a bath given or offered for 3/8/16.

4. A review of Patient # 4's medical record was conducted on 3/10/16. It revealed a discharge date and time of 3/9/16 at 3:48 p.m., with no documentation of a bath given or offered on that date.

5. A review of Patient #8's medical record was conducted on 3/10/16 and revealed an admission time and date of 3/6/16 at 3:40 a.m. and a discharge date and time of 3/7/16 at 7:00 p.m. No documentation of a bath given or offered was documented for this hospital stay.

6. A review of Patient # 10's medical record was conducted on 3/10/16 and revealed an admission date of 3/4/16, a discharge date of 3/8/16, and no documentation of a bath given or offered and no linen change on 3/7/16.

7. A brief interview was conducted with the Interim Nurse Manager, 4P unit, on 3/10/16 at 11:00 a.m., at which time she stated she did expect staff to give or offer a bath on the day of discharge, and agreed with the above findings. She added there is no current process for RN's to ensure the tasks have been completed each day.