HospitalInspections.org

Based on record review and interview, the hospital failed to:
a. document assistance or performance of hygiene activities
b. document activities performed by appropriately licensed nursing staff

This failed practice had the potential for increased risk to patient safety due to lack of accurately documenting patient care activities to allow medical and nursing decisions to be made by the health care team, and had the potential for adverse health outcomes for all patients in the hospital.

Finding:

Patient #13, a 53 year old male bariatric patient hospitalized for 13 days. In the medical record under the general title Hygiene, staff documented "moderate assistance"; there was no documentation of what moderate assistance included or what moderate assistance meant. During Patient #13's hospital stay, there was documentation of refusal of bathing on two days and two days warm wipes and peri care provided. There was no documentation of bathing provided or assisted for the remaining nine days of Patient # 13's stay.

Patient #16 a 61 year old female hospitalized for four days. In the medical record under the general title Hygiene, staff documented "moderate assistance"; there was no documentation of what moderate assistance included or what moderate assistance meant. There was no documentation of bathing provided or assisted for Patient #16's four day hospital stay.

CNO (02/20/19 at 3:00 pm) stated if staff marked "moderate assistance" it would be for the specific task and not under the general heading.




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Based on record review and interview, the hospital failed to document activities performed by appropriately licensed nursing staff

This failed practice had the potential for increased risk to patient safety due to inappropriately licensed nursing staff allowed to develop and implement the nursing assessment and care plan which effected nursing decisions regarding patient care provided.

Finding:

Patient #23 a 63 year old male admitted with a diagnosis of urinary tract infection. The electronic record review dated 02/11/19 showed Staff W, a Licensed Practical Nurse (LPN), initiated the care plan for Patient #23.

Hillcrest Medical Center Policy #27560.1 titled "Assess and Reassessment -NS-Corp (02/23/18)" stated "the RN will perform a comprehensive assessment of the patient's care needs, health status and responses to interventions ... Upon completion of the initial assessment, the RN should develop a nursing care plan focused on the problems and issues identified."

Hillcrest Medical Center Policy # 19560.2 titled "Licensed Practical Nurse (LPN) (10/05/17)" stated the LPN contributes to the assessment of the health status and development and modification of the patient's care plan.

The Oklahoma Board of Nursing "Patient Assessment Guidelines" stated in part:

The Registered Nurse (1) conducts comprehensive data collection, assesses for any anticipated changes in condition or treatment and/or emergent change in status of the client, (2) recognizes alterations in the client's condition ... (3) analyzes and synthesizes biological, psychological and social scientific data to determine rationale for nursing care needs of the client.

The Licensed Practical Nurse contributes to assessment of the patient by conducting a focused assessment of the client through collecting data, comparing the data collected to the client's previous condition, and determining when, to whom and where to report the data collected.

Staff W's personnel file showed documentation that she/he had a Registered Nurse (RN) license issued August 2018.

Staff I, CNO (02/21/19 at 12:31 pm) stated there was a lag time when a person changes positions/titles to when it showed up in the computer with the new title. During this lag time, medical record documentation indicated an inappropriately licensed nurse had provided services to the patient.