HospitalInspections.org

Based on open patient medical record review and interview, the nursing director failed to ensure that daily baths were provided to 3 of 4 patients currently hospitalized (pts. N2, 3 and N4).

Findings:
a. review of open medical records on the T4 and CDT (cardiac telemetry) nursing units on 3/1/11, indicated:
A. pt. N2 was lacking documentation in the medical record of having a bath on 2/25/11, 2/26/11, and 2/27/11
B. pt. N3 was lacking documentation in the medical record of having a bath on 2/18/11, 2/23/11 and 2/27/11
C. pt. N4 was lacking documentation in the medical record of having a bath on 2/28/11 and 3/1/11

b. at 10:30 AM and 4:05 PM on 3/1/11, interview with staff member NA indicated:
A. daily baths have been a performance improvement project on the nursing units recently
B. a clip board is being used by nurse aides in order to document when baths are performed for patients and sometimes this information is not being transferred to the on line/electronic medical record
C. in reviewing the clip boards, and comparing this information with the lack of documentation in the electonic record for pts N2, N3 and N4, it was found that the clip boards are lacking documentation for baths on the dates listed in a. above, as well
D. there is no written policy/procedure related to daily baths, it is a protocol and standard of practice that daily baths are to be provided to patients

c. interview with staff member NH at 12:45 PM on 3/1/11 indicated:
A. baths may not get done on the first shift, but this information is passed on to the next shift in hopes that they will follow through with helping the patient in hygiene care