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Based on interviews and record reviews, the facility failed to ensure nursing services were provided to meet the ongoing needs of patients in 1 out of 10 records reviewed (Patient #1).

The failure resulted in the patient's physical needs not being addressed.

FINDINGS

POLICY

According to the policy, Staffing Plan for the Provision of Care, the practice of nursing means the function of providing basic healthcare to assist people in coping with difficulties in daily living. Direct and indirect patient care services are responsible for ensuring the comfort, safety and personal hygiene needs of the patient are met.

According to the policy, Food Storage in Inpatient Care Area, unit staff is responsible for the proper food storage on inpatient care units.

Additionally, the Snacks for Patients policy stated clinical services staff will supervise the snack program to ensure service to every patient.

According to the policy, Personal Bedpans and Urinals, patients who are unable to use the bathroom facilities will be given his/her own bedpan or urinal.

REFERENCE

According to the Lippincott Manual of Nursing Practice 10th Edition, when caring for the older adult with urinary incontinence, nursing interventions include the use of incontinence aids such as pads and diapers and scheduled toileting to prevent wetting episodes (pp. 181-182).

1. The facility failed to ensure the toileting and hygiene needs of the patient were met.

a) Review of Patient #1's medical record revealed a female geriatric patient who arrived to the facility by ambulance on 10/05/15 at 8:30 p.m. and was admitted to the high functioning geriatric care unit. Documentation within the medical record showed Patient #1 remained on the ambulance stretcher throughout the initial intake process and was taken directly to his/her assigned room. The Patient Observation Sheet (Locator), dated 10/05/15 and 10/06/15, was used by patient care staff to show the location, activity and behavior of the patient and was completed every 15 minutes. The locator allowed patient care staff to document when assistance with personal care was provided to the patient.

Review of the General Note, dated 10/06/15 at 2:53 a.m., showed Patient #1 was awake during shift change, however, there was no documentation on the Locator or in the General Note section to show Patient #1 had been offered assistance with toileting.

At 9:41 a.m. on 10/06/15 the General Note section of Patient #1's medical record showed s/he was experiencing incontinence, was unable to walk and could barely turn in bed. There was no documentation on the Locator or within the General Note section to show Patient #1 had been provided a bedpan or other incontinence aid, such as a bedside commode.

b) On 1/04/16 at 1:28 p.m. an interview was conducted with a Mental Health Technician (MHT, Employee #10) with the delegated role to assist in the care of patients. Employee #10 stated the Locator was used to document the monitoring of every patient on all units in the facility and it was part of the responsibility of the MHT to assist in the physical care needs of patients, including bathing and toileting if needed. Employee #10 stated assistance with a diaper change or other incontinence aid should be documented on the Locator or in the General Note section of the patient medical record.

c) In an interview with Nurse #2, on 1/05/16, 11:23 a.m., s/he stated it was the responsibility of all patient care staff to assist in meeting the physical care needs of the patient, including toileting needs. Nurse #2 stated diapers and urinals had always been available for incontinent patients but s/he had never seen a bedpan or bedside commode in the facility.

d) On 1/05/16 at 12:18 p.m., an interview was conducted with Employee #4, Supervisor of the MHT staff. Employee #4 stated the MHTs were trained to address the personal care needs of patients and were expected to document all observations and care provided on the patient Locator or in the General Note section of the medical record. Employee #4 stated s/he had seen urinals and diapers in the facility supply room but could not produce a bedpan or bedside commode.

e) In an interview with the Director of Nursing (DON #8) on 1/06/16 at 8:35 a.m., s/he stated it was expected that all nursing and patient care staff would meet the needs of all patients no matter what the needs were. S/he stated it was also expected that patients who experience incontinence should be provided assistance with toileting and the assistance should be documented within the patient ' s medical record.

DON #8 stated s/he could not locate a bedpan or bedside commode within the facility but had initiated an order for them. DON #8 reviewed documentation in the medical record of Patient #1 and stated the physical care needs of the patient should have been addressed by nursing and patient care staff and documented within the medical record. S/he stated without the documentation it was not done.

2. The facility failed to provide nursing care to meet the dietary needs of the patient.

a) Review of the medical record of Patient #1 revealed a physician ' s order, dated 10/06/15 at 3:31 a.m., for a regular diet. The scheduled breakfast time for the geriatric unit to go to the cafeteria on 10/06/15 was 7:15 a.m. Documentation on the Locator for Patient #1 showed s/he was in his/her room awake and unable to walk. There was no documentation in the medical record to show s/he had been provided a meal or drink.

b) An interview was conducted with the Director of Dietary Services (Employee #9) on 1/04/16 at 11:31 a.m., Employee #9 stated all patients, with the exception of the acute geriatric unit, were expected to go to the cafeteria for meals and if a patient could not go to the cafeteria for any reason, it was the responsibility of nursing and patient care staff on each unit to take a meal back to the unit for the patient. Employee #9 stated the dietary services department provided snacks to each unit and ensured there was a stock of non-perishable food items on each unit for the patient care staff to serve patients when the cafeteria was closed. S/he stated there were always pre-made sandwiches available in the cafeteria kitchen for patient care staff to provide to patients who arrived outside of normal cafeteria operating hours.

c) In an interview conducted with an MHT (Employee #10) on 1/04/16 at 1:28 p.m., s/he stated it was part of the responsibilities of the MHT staff to provide meals for patients unable to leave their care unit to go to the cafeteria. Employee #10 stated the consumption or refusal of meals should be documented on the Locator or in the General note section of the patient medical record.

d) An interview was conducted with Nurse #2 on 1/05/16 at 11:23 a.m. Nurse #2 stated it was the responsibility of each unit's nursing and MHT staff to provide meals for patients unable to go to the cafeteria and any offer or refusal of a meal or snack should be documented on the Locator or General Note section of the medical record.

e) An interview was conducted with the Supervisor (Employee #4) of the MHT staff on 1/05/16 at 12:18 p.m. Employee #4 stated MHTs were expected to ensure patients unable to go to the cafeteria for meals would have a meal brought back to the unit and the meal consumption or refusal should be documented within the patient ' s medical record.

f) On 1/06/16 at 8:35 a.m., an interview was conducted with the Director of Nursing (DON #8). S/he stated it was expected that any patient arriving to the facility would be offered a meal or snack and something to drink and the acceptance or refusal by the patient would be documented in the patient ' s medical record.

DON #8 stated all staff on the geriatric care units had been re-trained on the provision of patient care on 10/28/15. S/he could not provide documentation to show all patient care staff on the geriatric units had attended the training or read the minutes of the training meeting. Furthermore, DON #8 could not verify patient care staff temporarily assigned to the geriatric units received training for the provision of care to the unique population of patients. S/he stated all patient care staff in the facility should be trained to provide for the dietary and toileting needs of any patient in the facility.

Patient #1 was transferred to a local Emergency Room on 10/06/15 at 10:00 a.m. Review of Patient #1's Intake and Output Flowsheet showed zero intake and no documentation of output during the 12 hour inpatient stay.