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2500 HOSPITAL DRIVE

MARTINSBURG, WV 25401

SUPERVISION OF CONTRACT STAFF

Tag No.: A0398

A. Based on medical record review and interview it was revealed the facility failed to ensure nursing staff followed all protocols by not documenting personal hygiene care in one (1) out of twenty (20) patients reviewed from 6th floor telemetry unit, patient #1. This failure has the potential to negatively affect all patients receiving care at the facility.

Findings include:

1. A record review was conducted of patient #1 on 04/26/21. The patient presented to the Emergency Department (ED) on 12/31/20 with a complaint of neck pain, nausea and vomiting. The patient was found to have atrial fibrillation (Afib) with rapid ventricular response (RVR). The patient was admitted to 6th floor telemetry unit at 12:00 a.m. No documentation was in the medical record of a bath, partial bath, indwelling urinary catheter care, oral care or perineal care. The patient left the facility on 01/04/21 at 4:14 p.m.

2. A telephone interview was conducted with the Registered Nurse (RN) #1 on 04/26/21 at 2:00 p.m. Regarding assisting patient #1 with her hygiene he stated, "There is nowhere to document if she was checked for incontinence, but I would have documented if I had to change her."

3. An interview was conducted with the Cardiac Care Technician (CCT) on 04/26/21 at 2:51 p.m. She did not remember patient #1. She stated, "I would always check a patient before they leave. I would only document if they actually needed cleaned up. I have been known not to document and have been re-educated about it recently."

4. An interview was conducted with the Nurse Manager on 04/26/21 at 2:30 p.m. She confirmed there was no documentation of patient #1 getting a bath, perineal care or indwelling urinary catheter care throughout her hospital stay.

B. Based on medical record review, document review and interview it was revealed the facility failed to ensure nursing staff followed nursing policies by not documenting results after indwelling urinary catheter removal in one (1) out of twenty (20) patients reviewed from 6th floor telemetry unit, patient #1. This failure has the potential to negatively affect all patients receiving care at the facility.

Findings include:

1. A record review was conducted of patient #1 on 04/26/21. The patient presented to the ED on 12/31/20 with a complaint of neck pain, nausea and vomiting. The patient was alert and oriented to person, place, time and situation. An indwelling urinary catheter was inserted. The patient was found to have atrial fibrillation (Afib) with rapid ventricular response (RVR). The patient was admitted to 6th floor telemetry unit at 12:00 a.m. The physician discharged the patient to home with home health on 01/04/21. The nurse documentation (RN #1) on 01/04/21 at 4:14 p.m. stated, "Foley (indwelling urinary catheter) removed ...." No further documentation was provided, after the indwelling urinary catheter was removed, the patient was able to void. The patient left the facility at 4:14 p.m.

2. The policy titled "Catheter Associated Urinary Tract Infection (CAUTI) Prevention," last revision date 08/2019, was reviewed on 04/27/21. The policy states in part on page two (2): "POLICY: ...After removal of the indwelling urinary catheter, the RN will ensure that the patient is voiding spontaneously .... Record the output volume and time of day with each void and each/any catheterization X 24 (twenty-four) hours."

3. A telephone interview was conducted with RN #1 on 04/26/21 at 2:00 p.m. Regarding patient #1 he stated, "I do not remember the patient at all. If I discontinued her Foley it would be in a discharge note. The patient would have to urinate before she left, but I don't necessarily document that."

4. An interview was conducted with the Nurse Manager on 04/26/21 at 2:30 p.m. Regarding the indwelling urinary catheter she stated, "The Foley was documented removed at 01/04/21 at 4:13 p.m. There is no further documentation of the patient voiding afterwards."