HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to ensure each patient's care and documentation of that care was completed according to facility policy and current standards of care for 3 of 5 patients of the hospital medical unit (Patients #1 and #5-6).

Findings were:

Facility policy entitled Daily Documentation (EMR), last revised 2/15, included the following:
"Nursing documentation will be done each shift with reassessments occurring at change of shift, change of caregiver, change in condition, PRN or per physician's order...
3. CNA's may document in the EMR for hygiene, safety, equipment, activity, I&O, daily weight, etc...
5. Pain assessment/reassessment will be completed according to pain management policies..."

Facility policy entitled Pain Management Assessment/Intervention, last revised 6/15, included the following:
"Should the patient express the presence of pain, a comprehensive pain assessment will be completed. Re-assessment will occur after interventions, change of condition and PRN...
PROCEDURE...
2. Should the patient express the presence of pain, a comprehensive pain assessment will be completed using the following criteria:
a. Date and time of pain
b. Assessment of pain
c. Pain Scale (faces, number, nonverbal, etc.)
d. Location of Pain
e. Other information that may assist in assessing pain such as vital signs, facial grimacing, etc..."

The medical record of Patient #1 included no percentages of meals consumed for 6/11/17. The record of Patient #5 included no percentages of meals consumed on 1/7/17. The percentages of meals consumed by these patients on the above dates were completely blank.

Documented pericare hygiene for Patient #1 was provided on 6/9/16 as "moderate assist" and on 6/10/16 as "independent." On admission, the patient's history and physical documented Patient #1 as "unable to get up or ambulate due to hip pain..." Showers were noted each day as "refused." There was no other documentation related to hygiene care. The patient was admitted on 6/8/16 and discharged on 6/11/16.

In an interview with the daughter of Patient #5, during a tour of the medical unit on the afternoon of 1/10/17, she was asked if she had any concerns regarding the care her mother had received while at the facility. She stated, "At the beginning, I had to ask for bathing...I was surprised that I had to tell them." In an interview with the daughter of Patient #6 during the same tour, she was asked if there were any concerns regarding the care her mother had received while at the hospital. She stated, "She hasn't had a bath since we've been here on this floor...and nothing today either. This is the third day she's been here on this floor..."

Hygiene care provided to Patient #5 was documented on 2 of 4 days reviewed. No documentation of refusal was made on the other 2 days. Patient #6 arrived on the unit on 1/6/17. There were no baths documented up to the date of survey, 1/10/17. Documentation stated that on 1/10/17 she had refused a shower.

The nursing care plan of Patient #1 included pain management as a goal. The patient received one acetaminophen-hydrocodone at 1:15 a.m. on 6/9/16 with no initial pain score noted and with no location or other information documented. She received an additional acetaminophen-hydrocodone on 6/9/16 at 7:46 p.m. No initial pain score, location of pain, or other pain assessment information was included in the record. No re-evaluation of pain was documented.

These findings were confirmed in an interview with Staff #1, Chief Nursing Officer, on the afternoon of 1/10/17 in a facility administrative meeting room. He agreed that nursing staff documentation was sporadic regarding hygiene, meals and pain assessments and interventions for the above patients. He stated, "We're going to have to look at our charting and the system prompts."