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ALBUQUERQUE - AMG SPECIALTY HOSPITAL, LLC
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on record reviews and interviews the facility failed to provide care in a safe setting by failing to utilize affective preventative care measures for 13 (P1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13 and 14) out of 14 patients selected .This failed practice is likely to lead increased risk of adverse events, direct physical and mental harm, and increased length of stay.
The findings are:
A. On 04/14/2021 at 1:35pm, interview with S2 (Chief Clinical Officer) recognized the identified contraindication between the practice of bathing patients every other day and the facility's "Skin Care Protocol" policy stating they are to be bathed daily. S2 reported that all aspects of patient hygiene are the responsibility of all clinical staff and must be done at a minimum of once a day. S2 stated that nursing is expected to assess a patient's skin at a minimum of every 2 hours, in conjunction with turning and positioning. S2 countered that Certified Nurse Assistant/Patient Care Technician (PCTs/CNAs) may perform the majority of turning and positioning, but that it is the burden of nursing to ensure that the actions are documented timely and accurately.
B. The record review of facility's "Skin Care Protocol" policy that has been effective since 01/2013 revealed:
1. Patients, both high and low risk for skin breakdown, will be bathed daily with mild soap, rinse, and dry thoroughly.
2. Inspect skin for signs and symptoms of breakdown at each patient repositioning (both high and low risk for skin breakdown); note any changes from the previous assessment on the nurse note.
3. Establish and record an individualized turning schedule if the patient is immobile. Frequency of the position change is titrated for the individual patient. Intervals may vary from 15 minutes to 2 hours. Evaluate the skin after each turning interval; if there is non-blanchable redness, increase the frequency of turning.
C. The record review of facility's "Turn Teams and Hourly Purposeful Rounding" policy that has been effective since 10/2016 revealed:
1. Each shift the Charge Nurse will identify the 3 members of the turn team, Turn and Positioning (T &P) and schedule the rounding for every 2 hours, on either even or odd hours, to reposition the patients who are unable to reposition themselves. The 3-person team is used to prevent: patient injury, skin shearing or breakdown dislodgement of lines/tubes and employee injury.
2. The attending nurse and attending Certified Nurse Assistant/Patient Care Technician (CNA/PCT) will alternately visit the patient and attend to the 5 P's of purposeful rounding (pain, potty, position, placement, and promise .) On day shift, the rounding will occur hourly. On the night shift, the rounding will occur every 2 hours.
3. Position- This is the incorporation of turns every 2 hours for patients requiring assisted turns. Patients not requiring turn team attention will have rounds performed only by the attending nurse or CNA/PCT alternately.
4. Evidence based outcomes of the turn team process: reduce/prevent hospital acquired wounds, reduce/prevent hospital acquired pneumonia, promotion of pulmonary toileting, improves patient comfort, reduces patient complaints, optimizes teamwork, improves customer service and confidence in our care.
D. Record review of P1's daily nursing assessment from 01/06/2021 to 03/05/2021 revealed:
1. On 01/10/2021, no documentation of T&P from 7:00 am-5:00 pm, no hourly round from 6:00 pm-6:00 am. No documentation of bathing or oral care for the entire day.
2. On 01/11/2021, no documentation of T&P documented or skin care for entire day. No documentation of bathing or oral care for the entire day.
3. On 01/12/2021, no documentation of T&P from 7:00 am- 5:00 pm. No documentation of bathing or oral care for the entire day.
4. On 01/13/2021-01/16/2021, No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
5. On 01/17/2021, no documentation of T&P from 6:00 pm- 6:00 am. No documentation of bathing for the entire day.
6. On 01/18/2021, no documentation of T&P from 4:00 pm- 6:00 am. No documentation of bathing for the entire day.
7. On 01/19/2021, no documentation of T&P from 4:00 pm- 6:00 am. No documentation of bathing for the entire day.
8. On 01/20/2021, no documentation of skin care 7:00 am- 5:00 pm. No documentation of bathing or oral care for the entire day.
9. On 01/21/2021, no documentation of T&P from 6:00 pm- 6:00 am. No documentation of bathing or oral care for the entire day.
10. On 01/22/2021, no documentation of skin care 7:00 am- 6:00 pm. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
11. On 01/23/2021-01/24/2021, no documentation of T&P from 4:00 pm- 6:00 am. No documentation of bathing for the entire day.
12. On 01/25/2021, no documentation of T&P and skin care. No documentation of oral care from 7:00 am- 6:00 am.
13. On 01/26/2021, no documentation of skin care 7:00 am-5:00 pm. No documentation of oral care from 7:00 am- 6:00 am.
14. On 01/27/2021, no documentation of skin care 7:00 am-5:00 pm. No documentation of oral care from 7:00 am- 6:00 am.
15. On 01/28/2021-01/31/2021. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
16. On 02/01/2021, no documentation of T&P or skin care from 7:00am- 6:00 pm. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
17. On 02/02/2021, no documentation of T&P or skin care from 7:00am- 6:00 pm. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
18. On 02/03/2021, no documentation of skin care from 7:00am- 6:00 pm. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
19. On 02/04/2021-02/06/2021. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
20. On 02/07/2021, no documentation of skin care from 7:00 am- 5:00 pm. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
21. On 02/08/2021, no documentation of T&P or skin care from 7:00 am- 7:00 pm. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
22. On 02/09/2021, no documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
23. On 02/10/2021-02/12/2021, no documentation of T&P from 6:00 pm-6:00 am. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
24. On 02/13/2021, no documentation of T&P from 6:00 pm-6:00 am. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
25. On 02/14/2021-02/15/2021, no documentation of T&P from 6:00 pm-6:00 am and no documentation of bathing for the entire day.
26. On 02/16/2021, no documentation of T&P from 6:00 pm-6:00 am. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
E. Record review of P2's daily nursing assessment from 03/05/2021 to 03/24/2021 revealed:
1. On 03/05/2021, no documentation of T&P from 7:00 am-11:00 am and no documentation of skin care for the entire day, and no documentation of bathing for the entire day.
2. On 03/12/2021, no documentation of T&P for the entire day and no skin care for the entire day, and no documentation of bathing for the entire day.
3. On 03/13/2021, no documentation of bathing for the entire day.
4. On 03/14/2021, no documentation of T&P from 7:00 am-7:00 pm, and no documentation of bathing for the entire day.
5. On 03/24/2021, no documentation of T&P from 6:00 pm-6:00 am and no documentation of skin care for the entire day.
6. On 03/15/2021, no documentation of bathing for the entire day.
7. On 03/17/2021, no documentation of bathing for the entire day.
8. On 03/23/2021, no documentation of bathing for the entire day.
9. On 03/24/2021, no documentation of bathing for the entire day.
F. Record review of P3's daily nursing assessment from 02/09/2021 to 03/16/2021 revealed:
1. On 02/10/2021, no documentation of bathing for the entire day.
2. On 02/11/2021, no documentation of T&P from 6:00 pm-6:00 am and no documentation of skin care for the entire day, and no documentation of bathing for the entire day.
3. On 02/12/2021-02/14/2021, no documentation of bathing for the entire day.
4. On 02/15/2021, no documentation of T&P from 6:00 pm-6:00 am and no documentation of skin care for the entire day.
5. On 02/16/2021, no documentation of T&P for the entire day, and no documentation of bathing for the entire day.
6. On 02/17/2021, no documentation of T&P from 6:00 pm- 6:00 am, and no documentation of skin care for the entire day, and no documentation of bathing for the entire day.
7. On 02/18/2021, no documentation of T&P from 6:00 pm- 6:00 am.
8. On 02/21/2021, no documentation of T&P from 7:00 am- 5:00 pm.
9. On 02/22/2021, no documentation of T&P from 5:00 pm- 6:00 am, and no documentation of bathing for the entire day.
10. On 02/23/2021-02/24/2021, no documentation of T&P from 6:00 pm- 6:00 am, and no documentation of bathing for the entire day.
11. On 02/25/2021, no documentation of T&P from 6:00 pm- 6:00 am and no documentation of skin care for the entire day, and no documentation of bathing for the entire day.
12. On 02/26/2021-02/27/2021, no documentation of bathing for the entire day.
13. On 03/02/2021, no documentation of T&P from 4:00 pm-6:00 am, and no documentation of skin care from 7:00 pm-6:00 am, no documentation of oral care for the entire day, no documentation of bathing for the entire day.
14. On 03/03/2021, no documentation of T&P from 6:00 pm-6:00 am, and no documentation of skin care from 7:00 pm-6:00 am, no documentation of bathing for the entire day.
15. On 03/04/2021, no documentation of T&P from 6:00 pm-6:00 am, and no documentation of skin care the entire day, no documentation of bathing for the entire day.
16. On 03/05/2021, no documentation of skin care from 7:00 am-5:00 pm, no documentation of bathing for the entire day.
17. On 03/06/2021, no documentation of T&P from 7:00 am-5:00 pm, and no documentation of skin care from 7:00 am- 5:00 pm, no documentation of bathing for the entire day.
18. On 03/09/2021, no documentation of T&P from 6:00 pm-6:00 am, and no documentation of skin care from 6:00 pm- 6:00 am, no documentation of bathing for the entire day.
19. On 03/10/2021-03/13/2021, no documentation of bathing for the entire day.
20. On 03/14/2021, no documentation of T&P from 7:00 am-5:00 pm, no documentation of bathing for the entire day.
21. On 03/16/2021, no documentation of T&P from 6:00 pm-6:00 am.
G. Record review of P4's daily nursing assessment from 03/28/2021 to 04/07/2021 revealed:
1. On 03/28/2021, no documentation of T&P for the entire day.
2. On 03/29/2021, no documentation of skin care or bathing for the entire day.
3. On 03/30/2021, no documentation for oral care for the entire day.
4. On 03/31/2021, no documentation of skin care or bathing for the entire day.
5. On 04/04/2021, no documentation of skin care or bathing for the entire day.
6. On 04/05/2021, no documentation of T&P from 7:00 am-5:00 pm, no documentation of skin care or bathing for the entire day.
7. On 04/07/2021, no documentation of T&P from 7:00 am-7:00 pm, no documentation of skin care or bathing for the entire day.
H. Record review of P5's daily nursing assessment from 01/26/2021 to 02/15/2021 revealed:
1. On 01/25/2021, no documentation of T&P from 6:00 pm- 6:00 am. No documentation of skin care from 6:00 pm- 6:00 am.
2. On 01/26/2021, no documentation of T&P from 7:00 am- 6:00 pm. No documentation of skin care from 7:00 am- 4:00 pm, no documentation of oral care for the entire day, and no documentation of bathing for the entire day.
3. On 01/27/2021, no documentation of T&P from 6:00 pm- 6:00 am, no documentation of oral care for the entire day, and no documentation of bathing for the entire day.
4. On 01/28/2021-01/29/2021, no documentation of oral care for the entire day, no documentation of bathing for the entire day.
5. On 01/30/2021-01/31/2021, no documentation of oral care for the entire day.
6. On 02/01/2021-02/02/2021, no documentation of oral care for the entire day, no documentation for bathing for the entire day.
7. On 02/03/2021, no documentation of T&P from 7:00 am-4:00pm, no documentation of oral care for the entire day.
8. On 02/06/2021-02/07/2021- no documentation of oral care for the entire day.
9. On 02/09/2021-02/14/2021, no documentation of oral care for the entire day, no documentation of bathing for the entire day.
10. On 02/15/2021, no documentation of T&P for the entire day, no documentation of oral care for the entire day, no documentation of bathing for the entire day.
11. On 02/16/2021, no documentation of T&P for the entire day, no documentation of oral care for the entire day, no documentation of bathing for the entire day.
I. Record review of P6's daily nursing assessment from 02/12/2021 to 03/05/2021 revealed:
1. On 02/12/2021, no documentation of skin care from 7:00 am-5:00 pm, no documentation of bathing for the entire day.
2. On 02/13/2021, no documentation of skin care from 7:00 am-5:00 pm, no documentation of bathing for the entire day.
3. On 02/14/2021, no documentation of bathing for the entire day.
4. On 02/15/2021, no documentation of T&P for the entire day, no documentation of bathing for the entire day.
5. On 02/16/2021, no documentation of T&P for the entire day, no documentation of bathing for the entire day.
6. On 02/17/2021, no documentation of T&P from 6:00 pm -6:00 am, no documentation of bathing for the entire day.
7. On 02/18/2021, no documentation of T&P from 6:00 pm -6:00 am
8. On 02/21/2021, no documentation of T&P from 7:00 am -6:00 pm, no documentation of bathing for the entire day.
9. On 02/25/2021, no documentation of T&P from 7:00 am -5:00 pm
10. On 02/26/2021, no documentation of T&P from 7:00 am -5:00 pm
11. On 03/03/2021, no documentation of bathing for the entire day.
12. On 03/04/2021, no documentation of skin care from 7:00 am-5:00 pm, no documentation of bathing for the entire day.
13. On 03/05/2021, no documentation of T&P from 6:00 pm -6:00 am, no documentation of bathing for the entire day.
J. Record review of P7's daily nursing assessment from 01/22/2021 to 02/24/2021 revealed:
1. On 01/22/2021, no documentation of T&P from 7:00 am -5:00 pm
2. On 01/27/2021, no documentation of T&P from 7:00 am -3:00 pm, no documentation of skin care from 7:00am-5:00 pm
3. On 01/28/2021, no documentation of skin care from 7:00 am-5:00 pm
4. On 01/29/2021, no documentation of skin care from 7:00 am-5:00 pm
5. On 02/02/2021, no documentation of T&P from 7:00 am -5:00 pm, no documentation of bathing for the entire day.
6. On 02/03/2021, no documentation of T&P from 10:00 am-7:00 pm, no documentation of bathing for the entire day.
7. On 02/07/2021, no documentation of bathing for the entire day.
8. On 02/08/2021, no documentation of T&P from 7:00 am-5:00 pm.
9. On 02/24/2021, no documentation of skin care from 6:00 pm- 6:00 am.
K. Record review of P8's daily nursing assessment from 02/20/2021 to 04/01/2021 revealed:
1. On 02/17/2021-02/19/2021, no documentation of bathing for the entire day.
2. On 02/20/2021, no documentation of T&P from 2:00 pm-6:00 am, no documentation of bathing for the entire day.
3. On 02/21/2021, no documentation of bathing for the entire day.
4. On 02/22/2021, no documentation of T&P from 7:00 am-7:00 pm, no documentation of bathing for the entire day.
5. On 02/23/2021, no documentation of bathing for the entire day.
6. On 02/26/2021, no documentation of skin care from 7:00 pm-6:00 am, no documentation of bathing for the entire day.
7. On 02/27/2021, no documentation of bathing for the entire day.
8. On 03/04/2021, no documentation of bathing for the entire day.
9. On 03/06/2021, no documentation of T&P from 7:00 am-4:00 pm, no documentation on skin care from 7:00 am-4:00 pm.
10. On 03/07/2021-03/11/2021, no documentation of bathing for the entire day.
11. On 03/14/2021-03/16/2021, no documentation of bathing for the entire day.
12. On 03/19/2021, no documentation of bathing for the entire day.
13. On 03/20/2021, no documentation of T&P from 7:00 am- 5:00 pm, no documentation of skin care from 7:00 am-5:00 pm
14. On 03/21/2021-03/26/2021, no documentation of bathing for the entire day.
15. On 03/27/2021, no documentation of T&P from 7:00 am- 5:00 pm, no documentation of bathing for the entire day.
16. On 03/28/2021, no documentation of bathing for the entire day.
17. On 03/30/2021, no documentation of T&P from 10:00 am- 4:00 pm
18. On 03/31/2021, no documentation of bathing for the entire day.
19. On 04/01/2021, no documentation of T&P from 5:00 pm- 6:00 am, no documentation of skin care from 5:00 pm-6:00 am, no documentation of bathing for the entire day.
L. Record review of P10's daily nursing assessment from 03/22/2021 to 04/02/2021 revealed:
1. On 03/22/2021, no documentation of T&P for entire day, no documentation of skin care from 7:00 am-5:00 pm, no documentation of bathing for the entire day.
2. On 03/23/2021, no documentation of bathing for the entire day.
3. On 04/02/2021, no documentation of T&P for entire day, no documentation of skin care from 7:00 am-5:00 pm.
M. Record review of P11's daily nursing assessment from 02/21/2021 revealed:
1. On 02/21/2021, no documentation of T&P from 7:00 am- 5:00 pm.
a. Record Review of P11's Provider Progress Note from 02/21/2021 revealed:
i. P11 complained to the provider that their call bell never gets answered
b. Record Review of P11's Complaint/Grievance Report from 02/21/2021 revealed:
i. At 6:00am P11 reported that they pushed their call button for the nurse for medication, blanket, and heating pad and received a response "we'll send someone in"
ii. At 9:00am P11 reported that a nurse entered her room but not for the needs she requested at 6:00am
iii. At 9:48 P11 again pushed her call light for the same needs as at 6:00am
iv. At 9:52 am P11 received the response that someone will come in
v. At 11:52am a Patient Care Technician came in but P11 reports they still never received the medication they requested.
vi. Corrective Action from facility: Assignment of a staff member to answer all call lights and communicate patient needs to either a nurse or a patient care technician
N. Record review of P12's daily nursing assessment from 01/07/2021 to 02/03/2021 revealed:
1. On 01/07/2021-01/10/2021, no documentation of bathing for the entire day.
2. On 01/12/2021-01/14/2021, no documentation of bathing for the entire day.
3. On 01/17/2021, no documentation of T&P from 7:00 am- 6:00pm
4. On 01/19/2021-01/20/2021, no documentation of bathing for the entire day.
5. On 01/21/2021, no documentation of T&P from 7:00 am- 5:00pm, no documentation of bathing for the entire day.
6. On 01/22/2021-01/23/2021, no documentation of bathing for the entire day.
7. On 01/24/2021, no documentation of T&P from 7:00 am- 6:00pm, no documentation of bathing for the entire day.
8. On 01/25/2021, no documentation of T&P from 7:00 am- 6:00 pm, no documentation of skin care for the entire day.
9. On 01/26/2021-02/02/2021, no documentation of bathing for the entire day.
10.. On 02/03/2021, no documentation of skin care for the entire day, no documentation of bathing for the entire day.
O. Record review of P13's daily nursing assessment from 01/06/2021 to 02/04/2021 revealed:
1. On 01/06/2021, no documentation of T&P from 6:00 pm-6:00 am, no documentation of skin care from 6:00 pm-6:00 am, no documentation of bathing for the entire day.
2. On 01/07/2021, no documentation of T&P for the entire day, no documentation of skin care for the entire day, no documentation of bathing for the entire day.
3. On 01/08/2021-01/10/2021, no documentation of bathing for the entire day.
4. On 01/12/2021, no documentation of T&P from 7:00 pm-6:00 am
5. On 01/13/2021, no documentation of T&P for the entire day, no documentation of bathing for the entire day.
P. Record Review of P13's Complaint/Grievance Report from 02/14/2021 revealed:
a. Complainant concerned about the hygiene of P13 "I noticed his [P13] eyes had a lot of mucus in the corners and on his eyeball, so I cleaned his eyes with my own tissues because there was no tissue box in the room. His body was extremely dry. I asked a tech (PCT) for some lotion and I put it on him. He had used the bathroom, so he had his diaper changed. After he was changed I saw Jevity (feeding tube formula, supplemental nutrition) from his peg (artificial feeding tube in the stomach) all over his gown and diaper. I told his nurse and she saw that she forgot to close the tube cap and just wiped him off with a towel and didn't change his gown or diaper. I am very disappointed with the care and because of the careless job of not keeping him clean."
b. Corrective Action from Facility: Documentation in P13's chart for 02/14/2021 does indicate they received a bed bath as schedules. Facility will reeducate staff on proper oral and eye care during annual skills fair.
6. On 01/17/2021, no documentation of T&P from 7:00 am-6:00 pm, no documentation of bathing for the entire day.
7. On 01/20/2021-01/24/2021, no documentation of bathing for the entire day.
8. On 01/25/2021, no documentation of T&P from 7:00 am-7:00 pm, no documentation of bathing for the entire day.
9. On 01/26/2021, no documentation of bathing for the entire day.
10. On 01/28/2021, no documentation of bathing for the entire day.
11. On 01/29/2021, no documentation of skin care from 7:00am- 6:00 pm, no documentation of bathing for the entire day.
12. On 01/30/2021-02/03/2021, no documentation of bathing for the entire day.
13. On 02/04/2021, no documentation of T&P from 6:00 pm-6:00 am.
Q. Record review of P14's daily nursing assessment from 08/07/2020 to 09/05/2020 revealed:
1. On 08/07/2020, no documentation of T&P from 8:00 am-6:00 pm, no documentation for skin care from 8:00 am- 5:00 pm
2. On 08/08/2020, no documentation of T&P from 8:00 am-5:00 pm, no documentation for skin care from 8:00 am- 5:00 pm
3. On 08/12/2021, no documentation of bathing for the entire day.
4. On 08/11/2020, no documentation of T&P from 7:00 am-6:00 pm, no documentation for skin care from 8:00 am- 6:00 pm
5. On 08/13/2020, no documentation of T&P from 8:00 pm-6:00 am, no documentation for skin care from 7:00 pm- 6:00 am
6. On 08/15/2021-08/17/2021, no documentation of bathing for the entire day.
7. On 08/19/2021, no documentation of bathing for the entire day, no documentation of bathing for the entire day.
8. On 08/20/2020, no documentation for skin care for the entire day.
9. On 08/21/2020, no documentation of T&P from 7:00 pm-6:00 am, no documentation for skin care from 6:00 pm- 6:00 am, no documentation of bathing for the entire day.
10. On 08/22/2020, no documentation of T&P from 7:00 am-5:00 pm, no documentation of bathing for the entire day.
11. On 08/25/2020, no documentation of T&P for the entire day.
12. On 08/26/2020, no documentation for skin care from 7:00 am- 5:00 pm, no documentation of bathing for the entire day.
13. On 08/31/2021, no documentation of bathing for the entire day.
14. On 09/02/2020, no documentation of T&P from 7:00 am-5:00 pm.
15. On 09/03/2020, no documentation of T&P from 7:00 am-5:00 pm, no documentation for skin care from 7:00 am- 5:00 pm, no documentation of bathing for the entire day.
16. On 09/04/2020, no documentation of T&P from 7:00 am-6:00 pm, no documentation for skin care from 7:00 am- 6:00 pm, no documentation of bathing for the entire day.
17. On 09/05/2020, no documentation of T&P for the entire day, no documentation for skin care from 7:00 am- 5:00 pm, no documentation of bathing for the entire day.
R. On 04/14/2021 at 11:00am, interview with S9 (Certified Nursing Assistant, CNA) indicated that regarding skin protection and interventions there is an expectation to turn and position patients every 2 hours, but that this can be delayed if the patient care technician (PCT) or CNA is busy with another task. When asked about the bathing routine, S9 confirmed that all patients are bathed every other day in a staggering schedule based on room assignment and that it is noted in a separate shower schedule.
S. On 04/14/2021 at 11:24 am, interview with S8 (PCT) stated that patient hygiene falls on the responsibility of the PCTs and CNAs to complete and that it follows a shower schedule. S8 continued by indicating that the facility has allowed an extra PCT/CNA on for half of a morning shift to assist with bathing as the others can become busy having to do other tasks. Regarding skin interventions, S8 confirms the expectation is to have patients turned and positioned every 2 hours but that it can be delayed due to conflicting duties.
T. On 04/14/2021 at 12:00pm, interview with S7 (Licensed Practical Nurse, LPN) reinforced that it is the responsibility of the PCTs/CNAs to ensure that patients are turned and positioned every 2 hours, but that it is the responsibility of nursing to ensure that the patient's skin is clean, dry, and intact. S7 also indicated that some nurses do not engage in teamwork or do not assist the PCTs/CNAs in turning patients.
U. On 04/14/2021 at 11:33 am, interview with S6 (Registered Nurse, RN) confirmed that turning schedules are the responsibility of the PCTs/CNAs.
V. On 04/14/2021 at 1:07 pm, interview with S5 (Charge Registered Nurse) explained that the expectation for bedside nurses regarding hygiene is to ensure that their patient's skin is clean, dry, and intact and that their mouth is clean and moist. If hygiene or skin measures are not done by the PCTs/CNAs then the nurse must complete them as they have responsibility to their patient. S5 confirmed that the shower schedule is not part of a patient's medical record, nor does it identify if a specific patient has been bathed. The shower schedule identifies which PCT/CNA bathed a patient based on their room but there is a high amount of changing of patient's room assignments so it's hard to correlate.
PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT
Tag No.: A0145
Based on record reviews and interviews the facility failed to ensure that patients receive care in a setting free from all forms of abuse, including neglect for 13 (P1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13 and 14) out of 14 patients selected. This failed practice is likely to lead to an increased risk for adverse events, such as infection and deterioation of oral hygiene, emotional distress, and worsening of clinical outcomes.
The findings are:
Patient #1 (P1) findings:
A. Record Review of P1's Nursing Care Plan from 01/06/2021 revealed:
1. P1 has a nursing diagnosis of self-care deficit and it is indicated that P1 is unable to perform any self-care activities due to quadriplegia (loss of sensory and motor functions in all 4 limbs). It is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living (activites done daily as part of normal habits bathing, oral hygiene, and toileting)
2. P1 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned (T&P, process of positioning a patient in a way to shift weight and prevent the development of pressure related skin breakdown) every 2 hours and that the skin will be kept clean, dry (free from moisture associated with sweat, urine, or stool) and moisturized.
B. Record Review of P1's Nursing Assessments from 01/07/2021-03/05/2021 revealed:
1. On 01/10/2021: no documentation of T&P from 7:00 pm- 6:00 am, no documentation of skin care from 6:00 pm- 6:00 am and no documentation of bathing or oral hygiene performed for the entire day.
2. On 01/11/2021 no documentation of T&P or skin care for the entire day and no documentation of bathing or oral hygiene performed for the entire day.
3. On 01/12/2021: no documentation of T&P from 7:00 am-5:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
4. On 01/13/2021-01/16/2021 no documentation of bathing or oral hygiene performed for the entire day.
5. On 01/17/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of bathing for the entire day.
6. On 01/18/2021 no documentation of Turning and Positioning from 4:00 pm-6:00 am and no documentation of bathing for the entire day.
7. On 01/20/2021 no documentation of skin care done from 7:00 am-5:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
8. On 01/21/2021 no documentation of T&P done from 6:00 pm- 6:00 am and no documentation of bathing or oral hygiene performed for the entire day.
9. On 01/22/2021 no documentation of skin care done from 7:00 am-6:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
10. On 01/25/2021 no documentation of T&P from 7:00 am-6:00 pm, no documentation of skin care done from 7:00 am-6:00 pm and no documentation of bathing.
11. On 01/26/2021 no documentation of skin care done from 7:00 am-5:00 pm, and no documentation of bathing for the entire day.
12. On 01/28/2021-01/31/2021 no documentation of bathing or oral hygiene performed for each day.
13. On 02/01/2021 no documentation of T&P done from 7:00 am-6:00 pm, no documentation skin care from 7:00 am-6:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
14. On 02/02/2021 no documentation of T&P from 7:00 am-6:00 pm, no documentation of skin care from 7:00 am-6:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
15. On 02/03/2021 no documentation of skin care done from 7:00 am-6:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
16. On 02/04/2021-02/09/2021 no documentation of bathing or oral hygiene performed for each day.
17. On 02/07/2021 no documentation of skin care done from 7:00 am-6:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
18. On 02/08/2021 no documentation of T&P from 7:00 am-7:0 0pm, no documentation of skin care from 7:00 am -6:00 pm, no documentation of bathing or oral hygiene performed for the entire day.
19. On 02/10/2021 no documentation of T&P from 7:00 am-2:00 pm, no documentation of skin care from 7:00 am-1:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
20. On 02/11/2021- 02/14/2021 no documentation of T&P from 6:00 pm-6:00 am and no documentation of bathing or oral hygiene performed for each day.
21. On 02/15/2021 no documentation of T&P from 10:00 am-7:0 0 pm and no documentation of bathing for the entire day.
22. On 02/16/2021 no documentation of T&P from 6:00 pm-6:00 am and no documentation of bathing or oral hygiene performed for the entire day.
Patient #2 (P2) findings:
C. Record Review of P2's Nursing Care Plan from 03/03/2021 revealed:
1. P2 has a nursing diagnosis of self-care deficit regarding bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P2 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
D. Record Review of P2's Nursing Assessments from 03/05/2021- 03/24/2021 revealed:
1. On 03/05/2021 no documentation of T&P from 7:00 am-11:00 am, no documentation of bathing for the entire day.
2. On 03/12/2021 no documentation of T&P from 7:00 am-6:0 0 pm, no documentation of skin care from 7:00 am-6:00 pm, no documentation of bathing for the entire day.
3. On 03/14/2021 no documentation of T&P from 7:00 am-7:00 pm, no documentation of bathing for the entire shift.
4. On 03/24/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of skin care from 6:00 pm-6:00 am, no documentation of bathing for the entire shift.
Patient #3 (P3) findings:
E. Record Review of P3's Nursing Care Plan from 02/09/2021 revealed:
1. P3 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P3 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
F. Record Review of P3's Nursing Assessment from 02/11/2021- 03/16/2021 revealed:
1. On 02/11/2021 no documentation of T&P from 6:00pm-6:00am, no documentation of skin care from 6:00pm-6:00 am, no documentation of bathing for the entire day.
2. On 02/12/2021- 02/14/2021 no documentation of bathing for the entire day.
3. On 02/15/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of skin care from 6:00 pm-6:00 am.
4. On 02/16/2021 no documentation of T&P for the entire day.
5. On 02/17/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of skin care for the entire day.
6. On 02/18/2021 no documentation of T&P from 6:00 pm-6:00 am.
7. On 02/21/2021 no documentation of T&P from 7:00 am-5:00 pm.
8. On 02/22/2021 no documentation of T&P from 5:00 pm-6:00 am, no documentation of bathing for the entire day.
9. On 02/23/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of bathing for the entire day.
10. On 02/24/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of bathing for the entire day.
11. On 02/25/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of skin care for the entire day, no documentation of bathing for the entire day.
12. On 03/02/2021 no documentation of T&P from 4:00 pm-6:00 am, no documentation of skin care done from 6:00pm-6:00am, no documentation of bathing or oral hygiene done for the entire day.
13. On 03/03/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of skin care done from 7:00pm-6:00am, no documentation of bathing for the entire day.
14. On 03/04/2021 no documentation of T&P from 6:00pm-6:00am, no documentation of bathing for the entire day.
15. On 03/05/2021 no documentation of skin care done from 7:00am-5:00pm, no documentation of bathing for the entire day.
16. On 03/06/2021 no documentation of T&P from 7:00am-5:00pm, no documentation of skin care done from 7:00am-5:00pm, no documentation of bathing for the entire day.
17. On 03/09/2021 no documentation of T&P from 6:00pm-6:00am, no documentation of skin care done from 6:00pm-6:00am, no documentation of bathing for the entire day.
18. On 03/14/2021 no documentation of T&P from 7:00am-5:00pm, no documentation of bathing for the entire day.
19. On 03/16/2021 no documentation of T&P from 6:00pm-6:00am.
Patient #4 (P4) findings:
G. Record Review of P4's Nursing Care Plan from 03/20/2021 revealed:
1. P4 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P4 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
H. Record Review of P4's Nursing Assessments from 03/28/2021-04/07/2021 revealed:
1. On 03/28/2021 no documentation of T&P for the entire day.
2. On 03/29/2021 no documentation of bathing for the entire day.
3. On 04/05/2021 no documentation of T&P from 7:00am- 5:00pm.
4. On 04/07/2021 no documentation of T&P from 7:00am- 7:00pm, no documentation of bathing for the entire day.
Patient #5 (P5) findings
I. Record Review of P5's Nursing Care Plan from 01/20/2021 revealed:
1. P5 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P5 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
J. Record Review of P5's Nursing Assessments from 01/25/2021-02/16/2021 revealed:
1. On 01/25/2021 no documentation of T&P from 6:00pm- 6:00am, no documentation of skin care done from 6:00pm- 6:00am
2. On 01/26/2021 no documentation of T&P from 7:00am-6:00pm, no documentation of skin care done from
7:00am- 4:00pm, no documentation of bathing or oral hygiene for the entire day
3. On 01/27/2021 no documentation of T&P from 6:00pm- 6:00am, no documentation of bathing or oral hygiene for the entire day
4. On 01/28/2021 - 02/02/2021 no documentation of bathing or oral hygiene for the entire day
5. On 02/03/2021 no documentation of T&P from 7:00am- 4:00pm, no documentation of oral hygiene for the entire day
6. On 02/09/2021- 02/14/2021 no documentation of bathing or oral hygiene for the entire day
7. On 02/15/2021 and 02/16/2021 no documentation of T&P for the entire day, no documentation of bathing or oral hygiene for the entire day
K.Record Review of P6's Nursing Care Plan from 02/11/2021 revealed:
1.P6 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2.P6 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
L.Record Review of P6's Nursing Assessments from 02/12/2021- 03/05/2021 revealed:
1. On 02/12/2021 and 02/13/2021 no documentation of skin care done from 7:00am- 5:00pm, no documentation of bathing for the entire day
2. On 02/15/2021 and 02/16/2021 no documentation of T&P the entire day
3. On 02/17/2021 and 02/18/2021 no documentation of T&P from 6:00pm- 6:00am, no documentation of bathing for the entire day
4. On 02/21/2021 no documentation of T&P from 7:00am- 6:00pm
5. On 02/25/2021 and 02/26/2021 no documentation of T&P from 7:00am- 5:00pm
6. On 03/04/2021 no documentation of skin care done from 7:00am- 5:00pm, no documentation of bathing during the entire day, no documentation of bathing during the entire day
7. On 03/05/2021 no documentation of skin care done from 6:00pm- 6:00am, no documentation of bathing for the entire day, no documentation of bathing for the entire day
M. Record Review of P7's Plan of Care from 01/21/2021 revealed:
1. P7 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P7 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
N. Record Review of P7's Nursing Assessments from 01/21/2021- 02/24/2021 revealed:
1. On 01/22/2021 no documentation of T&P from 7:00am- 5:00pm
2. On 01/27/2021 no documentation of T&P from 7:00am- 3:00pm, no documentation of skin care done from 7:00am- 5:00pm
3. On 01/28/2021 no documentation of T&P from 7:00am- 5:00pm
4. On 01/29/2021 no documentation of T&P from 7:00am- 5:00pm
5. On 02/02/2021 no documentation n of T&P from 7:00am- 5:00pm, no documentation of bathing for the entire day
6. On 02/03/2021 no documentation of T&P from 10:00am- 7:00pm, no documentation of bathing for the entire day
7. On 02/08/2021 no documentation of T&P from 7:00am- 5:00pm
8. On 02/24/2021 no documentation of T&P from 6:00pm- 6:00am
O. Record Review of P8's Nursing Care Plan from 02/17/2021 revealed:
1. P8 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P8 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
P. Record Review of P8's Nursing Assessment from 02/20/2021- 04/01/2021 revealed:
1. On 02/20/2021 no documentation of T&P from 2:00pm- 6:00am
2. On 02/22/2021 no documentation of T&P from 7:00am- 7:00pm
3. On 02/26/2021 no documentation of skin care done from 7:00pm-6:00am
4. On 03/06/2021 no documentation of T&P from 7:00am- 4:00pm, no documentation of skin care done from 7:00am- 4:00pm
5. On 03/07/2021- 03/11/2021 no documentation of bathing for the entire day
6. On 03/14/2021- 03/16/2021 no documentation of bathing for the entire day
7. On 03/20/2021 no documentation of T&P from 7:00am- 5:00pm, no documentation of skin care from 7:00am- 5:00pm
8. On 03/21/2021-03/26/2021 no documentation of bathing for the entire day
9. On 03/27/2021 no documentation of T&P from 7:00am- 5:00pm
10. On 03/30/2021 no documentation of T&P from 10:00am- 4:00pm
11. On 04/01/2021 no documentation of T&P from 5:00pm- 6:00am, no documentation of skin care done from 5:00pm- 6:00am, no documentation of bathing for the entire day
Q. Record Review of P10's Nursing Care Plan from 03/18/2021 revealed:
1. P10 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P10 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
R. Record Review of P10's Nursing Assessments from 03/22/2021- 04/08/2021
1. On 03/22/2021 no documentation of T&P from 7:00am- 5:00pm, no documentation of bathing for the entire day
2. On 04/02/2021 no documentation of T&P from 7:00am- 5:00pm, no documentation of skin care from 7:00am- 5:00pm
S. Record Review of P11's Nursing Care Plan from 02/09/2021 revealed:
1. P11 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P11 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
T. Record Review of P11's Nursing Assessments from 02/21/2021 revealed:
1. No documentation of skin care done from 7:00am- 5:00pm
U. Record Review of P11's Provider Progress Note from 02/21/2021 revealed:
1. P11 complained to the provider that their call bell never gets answered
V. Record Review of P11's Complaint/Grievance Report from 02/21/2021 revealed:
1. At 6:00am P11 reported that they pushed their call button for the nurse for medication, blanket, and heating pad and received a response "we'll send someone in"
2. At 9:00am P11 reported that a nurse entered her room but not for the needs she requested at 6:00am
3. At 9:48 P11 again pushed her call light for the same needs as at 6:00am
4. At 9:52 am P11 received the response that someone will come in
5. At 11:52am a Patient Care Technician came in but P11 reports they still never received the medication they requested.
6. Corrective Action from facility's investigation: Assignment of a staff member to answer all call lights and communicate patient needs to either a nurse or a patient care technician
W. Record Review of P12's Nursing Care Plan from 01/07/2021 revealed:
1. P12 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P12 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
X. Record Review of P12's Nursing Assessments from 01/07/2021-02/03/2021 revealed:
1. On 01/07/2021-01/10/2021 no documentation of bathing for the entire day
2. On 01/12/2021-01/14/2021 no documentation of bathing for the entire day
3. On 01/17/2021 no documentation of T&P from 7:00am- 6:00pm
4. On 01/19/2021-01/29/2021 no documentation of bathing for the entire day
5. On 02/03/2021 no documentation of skin care and bathing done for the entire day
Y. Record Review of P13's Nursing Care Plan from 12/29/2020 revealed:
1. P13 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P13 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
Z. Record Review of P13's Nursing Assessments from 01/06/2021- 02/04/2021
1. On 01/06/2021 no documentation of T&P from 6:00pm- 6:00am, no documentation of skin care done from 6:00pm- 6:00am, no documentation of bathing done for the entire day
2. On 01/07/2021 no documentation of T&P, skin care, or bathing done for the entire day
3. On 01/08/2021- 01/10/2021 no documentation of bathing for the entire day
4. On 01/12/2021 no documentation of T&P from 7:00pm- 6:00am
5. On 01/13/2021 no documentation of T&P from 9:00am- 6:00am
6. On 01/20/2021- 01/24/2021 no documentation of bathing done for the entire day
7. On 01/25/2021 no documentation of T&P from 7:00am- 6:00pm, no documentation of bathing done for the entire day
8. On 01/29/2021 no documentation of skin care done from 7:00am- 6:00pm, no documentation of bathing done for the entire day
9. On 01/30/2021- 02/03/2021 no documentation of skin care done for the entire day
10. On 02/04/2021 no documentation of T&P from 6:00pm- 6:00am
AA. Record Review of P13's Complaint/Grievance Report from 02/14/2021 revealed:
1. Complainant concerned about the hygiene of P13 "I noticed his [P13] eyes had a lot of mucus in the corners and on his eyeball so I cleaned his eyes with my own tissues because there was no tissue box in the room. His body was extremely dry. I asked a tech (PCT) for some lotion and I put it on him. He had used the bathroom, so he had his diaper changed. After he was changed I saw Jevity (feeding tube formula, supplemental nutrition) from his peg (artificial feeding tube in the stomach) all over his gown and diaper. I told his nurse and she saw [noticed] that she forgot to close the tube cap and just wiped him off with a towel and didn't change his gown or diaper. I am very disappointed with the care and because of the careless job of not keeping him clean."
BB. Record Review of P14's Nursing Care Plan from 08/06/2020 revealed:
1. P14 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P14 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized
CC. Record Review of P14's Nursing Assessments from 08/07/2020- 09/05/2020 revealed:
1. On 08/07/2020 no documentation of T&P from 8:00am- 6:00pm, no documentation of skin care done from 8:00am- 5:00pm
2. On 08/08/2020 no documentation of T&P from 8:00am- 5:00pm, no documentation of skin care done from 8:00am- 5:00pm
3. On 08/11/2020 no documentation of T&P from 7:00am- 6:00pm, no documentation of skin care done from 8:00am- 6:00pm
4. On 08/13/2020 no documentation of T&P from 8:00pm- 6:00am, no documentation of skin care done from 6:00pm- 6:00am
5. On 08/22/2020 no documentation of T&P from 7:00am- 5:00pm, no documentation of skin care done the entire day
6. On 08/25/2020 no documentation of T&P from 8:00am- 6:00am
7. On 08/26/2020 no documentation of skin care done from 7:00am- 5:00pm
8. On 09/02/2020 no documentation of T&P from 7:00am- 5:00pm
9. On 09/03/2020 no documentation of T&P from 7:00am- 5:00pm, no documentation of skin care done from 7:00am- 5:00pm, no documentation of skin care done the entire day
10. On 09/04/2020 no documentation of T&P from 7:00am- 6:00pm, no documentation of skin care done from 7:00am- 6:00pm, no documentation of skin care done the entire day
11. On 09/05/2020 no documentation of T&P for the entire day, no documentation of skin care done from 7:00am- 5:00pm, no documentation of skin care done the entire day
DD. Record Review of facility's "Turn Teams and Hourly Purposeful Rounding" policy effective since 10/2016 revealed:
1. Turn Teams: each shift the charge nurse will identify the 3 members of the turn team and schedule the rounding for every 2 hours, to reposition patients who are unable to reposition themselves
2. Evidenced based outcomes of turn team process: reduce/prevent hospital acquired wounds and pneumonia (lung infection), improves patient comfort, optimizes teamwork, and reduces patient complaints
EE. Record Review of facility's "Skin Care Protocol" policy effective since 01/2013 revealed:
1. Patients, both at low and high risk for skin breakdown, are to be bathed daily with mild soap, rinse, and dry thoroughly
2. Patients, both at low and high risk for skin breakdown, are to have their skin inspected for signs and symptoms of breakdown at each patient repositioning
3. Patients, both at low and high risk for skin breakdown, are to have an established and recorded turning schedule. Intervals may vary from 15 minutes to 2 hours. Evaluate the skin after each turning interval.
FF. On 04/14/2021 at 11:00am, interview with S9 (Certified Nursing Assistant, CNA) indicated that regarding skin protection and interventions there is an expectation to turn and position patients every 2 hours, but that this can be delayed if the patient care technician (PCT) or CNA is busy with another task. When asked about the bathing routine, S9 confirmed that all patients are bathed every other day in a staggering schedule based on room assignment and that it is noted in a separate shower schedule.
GG. On 04/14/2021 at 11:24am, interview with S8 (PCT) stated that patient hygiene falls on the responsibility of the PCTs and CNAs to complete and that it follows a shower schedule. S8 continued by indicating that the facility has allowed an extra PCT/CNA on for half of a morning shift to assist with bathing as the others can become busy having to do other tasks. Regarding skin interventions, S8 confirms the expectation is to have patients turned and positioned every 2 hours but that it can be delayed due to conflicting duties.
HH. On 04/14/2021 at 12:00pm, interview with S7 (Licensed Practical Nurse, LPN) reinforced that it is the responsibility of the PCTs/CNAs to ensure that patients are turned and positioned every 2 hours, but that it is the responsibility of nursing to ensure that the patient's skin is clean, dry, and intact. S7 also indicated that some nurses do not engage in teamwork or do not assist the PCTs/CNAs in turning patients.
II. On 04/14/2021 at 11:33am, interview with S6 (Registered Nurse, RN) confirmed that turning schedules are the responsibility of the PCTs/CNAs.
JJ. On 04/14/2021 at 1:07pm, interview with S5 (Charge Registered Nurse) explained that the expectation for bedside nurses regarding hygiene is to ensure that their patient's skin is clean, dry, and intact and that their mouth is clean and moist. If hygiene or skin measures are not done by the PCTs/CNAs then the nurse must complete them as they have responsibility to their patient. S5 confirmed that the shower schedule is not part of a patient's medical record, nor does it identify if a specific patient has been bathed. The shower schedule identifies which PCT/CNA bathed a patient based on their room but there is a high amount of changing of patient's room assignments so it's hard to correlate.
KK. On 04/14/2021 at 2:17pm, interview with S4 (Wound Care Registered Nurse) reported that patients are bathed every other day, despite it being in contradiction to facility's policy. S4 confirmed that wound care was not consulted prior to implanting a change in bathing routines.
LL. On 04/14/2021 at 1:35pm, interview with S2 (Chief Clinical Officer) recognized the identified contraindication between the practice of bathing patients every other day and the facility's "Skin Care Protocol" policy stating they are to be bathed daily. S2 reported that all aspects of patient hygiene are the responsibility of all clinical staff and must be done at a minimum of once a day. S2 stated that nursing is expected to assess a patient's skin at a minimum of every 2 hours, in conjunction with turning and positioning. S2 countered that PCTs/CNAs may perform the majority of turning and positioning, but that it is the burden of nursing to ensure that the actions are documented timely and accurately.
NURSING CARE PLAN
Tag No.: A0396
Based on record reviews and interviews the facility failed to ensure nursing staff adheres to current patient care plans and provide appropriate care for the attainment of goals for 13 (P1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14) out of 14 patients selected. This failed practice is likely to lead to increase risk of adverse event, physical and mental anguish, and worsening of clinical outcomes.
The findings are:
Patient #1 (P1) findings:
A. Record Review of P1's Nursing Care Plan from 01/06/2021 revealed:
1. P1 has a nursing diagnosis of self-care deficit and it is indicated that P1 is unable to perform any self-care activities due to quadriplegia (loss of sensory and motor functions in all 4 limbs). It is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living (activites done daily as part of normal habits bathing, oral hygiene, and toileting)
2. P1 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned (T&P, process of positioning a patient in a way to shift weight and prevent the development of pressure related skin breakdown) every 2 hours and that the skin will be kept clean, dry (free from moisture associated with sweat, urine, or stool) and moisturized.
B. Record Review of P1's Nursing Assessments from 01/07/2021-03/05/2021 revealed:
1. On 01/10/2021: no documentation of T&P from 7:00 pm- 6:00 am, no documentation of skin care from 6:00 pm- 6:00 am and no documentation of bathing or oral hygiene performed for the entire day.
2. On 01/11/2021 no documentation of T&P or skin care for the entire day and no documentation of bathing or oral hygiene performed for the entire day.
3. On 01/12/2021: no documentation of T&P from 7:00 am-5:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
4. On 01/13/2021-01/16/2021 no documentation of bathing or oral hygiene performed for the entire day.
5. On 01/17/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of bathing for the entire day.
6. On 01/18/2021 no documentation of Turning and Positioning from 4:00 pm-6:00 am and no documentation of bathing for the entire day.
7. On 01/20/2021 no documentation of skin care done from 7:00 am-5:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
8. On 01/21/2021 no documentation of T&P done from 6:00 pm- 6:00 am and no documentation of bathing or oral hygiene performed for the entire day.
9. On 01/22/2021 no documentation of skin care done from 7:00 am-6:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
10. On 01/25/2021 no documentation of T&P from 7:00 am-6:00 pm, no documentation of skin care done from 7:00 am-6:00 pm and no documentation of bathing.
11. On 01/26/2021 no documentation of skin care done from 7:00 am-5:00 pm, and no documentation of bathing for the entire day.
12. On 01/28/2021-01/31/2021 no documentation of bathing or oral hygiene performed for each day.
13. On 02/01/2021 no documentation of T&P done from 7:00 am-6:00 pm, no documentation skin care from 7:00 am-6:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
14. On 02/02/2021 no documentation of T&P from 7:00 am-6:00 pm, no documentation of skin care from 7:00 am-6:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
15. On 02/03/2021 no documentation of skin care done from 7:00 am-6:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
16. On 02/04/2021-02/09/2021 no documentation of bathing or oral hygiene performed for each day.
17. On 02/07/2021 no documentation of skin care done from 7:00 am-6:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
18. On 02/08/2021 no documentation of T&P from 7:00 am-7:0 0pm, no documentation of skin care from 7:00 am -6:00 pm, no documentation of bathing or oral hygiene performed for the entire day.
19. On 02/10/2021 no documentation of T&P from 7:00 am-2:00 pm, no documentation of skin care from 7:00 am-1:00 pm and no documentation of bathing or oral hygiene performed for the entire day.
20. On 02/11/2021- 02/14/2021 no documentation of T&P from 6:00 pm-6:00 am and no documentation of bathing or oral hygiene performed for each day.
21. On 02/15/2021 no documentation of T&P from 10:00 am-7:0 0 pm and no documentation of bathing for the entire day.
22. On 02/16/2021 no documentation of T&P from 6:00 pm-6:00 am and no documentation of bathing or oral hygiene performed for the entire day.
Patient #2 (P2) findings:
C. Record Review of P2's Nursing Care Plan from 03/03/2021 revealed:
1. P2 has a nursing diagnosis of self-care deficit regarding bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P2 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
D. Record Review of P2's Nursing Assessments from 03/05/2021- 03/24/2021 revealed:
1. On 03/05/2021 no documentation of T&P from 7:00 am-11:00 am, no documentation of bathing for the entire day.
2. On 03/12/2021 no documentation of T&P from 7:00 am-6:0 0 pm, no documentation of skin care from 7:00 am-6:00 pm, no documentation of bathing for the entire day.
3. On 03/14/2021 no documentation of T&P from 7:00 am-7:00 pm, no documentation of bathing for the entire shift.
4. On 03/24/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of skin care from 6:00 pm-6:00 am, no documentation of bathing for the entire shift.
Patient #3 (P3) findings:
E. Record Review of P3's Nursing Care Plan from 02/09/2021 revealed:
1. P3 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P3 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
F. Record Review of P3's Nursing Assessment from 02/11/2021- 03/16/2021 revealed:
1. On 02/11/2021 no documentation of T&P from 6:00pm-6:00am, no documentation of skin care from 6:00pm-6:00 am, no documentation of bathing for the entire day.
2. On 02/12/2021- 02/14/2021 no documentation of bathing for the entire day.
3. On 02/15/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of skin care from 6:00 pm-6:00 am.
4. On 02/16/2021 no documentation of T&P for the entire day.
5. On 02/17/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of skin care for the entire day.
6. On 02/18/2021 no documentation of T&P from 6:00 pm-6:00 am.
7. On 02/21/2021 no documentation of T&P from 7:00 am-5:00 pm.
8. On 02/22/2021 no documentation of T&P from 5:00 pm-6:00 am, no documentation of bathing for the entire day.
9. On 02/23/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of bathing for the entire day.
10. On 02/24/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of bathing for the entire day.
11. On 02/25/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of skin care for the entire day, no documentation of bathing for the entire day.
12. On 03/02/2021 no documentation of T&P from 4:00 pm-6:00 am, no documentation of skin care done from 6:00pm-6:00am, no documentation of bathing or oral hygiene done for the entire day.
13. On 03/03/2021 no documentation of T&P from 6:00 pm-6:00 am, no documentation of skin care done from 7:00pm-6:00am, no documentation of bathing for the entire day.
14. On 03/04/2021 no documentation of T&P from 6:00pm-6:00am, no documentation of bathing for the entire day.
15. On 03/05/2021 no documentation of skin care done from 7:00am-5:00pm, no documentation of bathing for the entire day.
16. On 03/06/2021 no documentation of T&P from 7:00am-5:00pm, no documentation of skin care done from 7:00am-5:00pm, no documentation of bathing for the entire day.
17. On 03/09/2021 no documentation of T&P from 6:00pm-6:00am, no documentation of skin care done from 6:00pm-6:00am, no documentation of bathing for the entire day.
18. On 03/14/2021 no documentation of T&P from 7:00am-5:00pm, no documentation of bathing for the entire day.
19. On 03/16/2021 no documentation of T&P from 6:00pm-6:00am.
Patient #4 (P4) findings:
G. Record Review of P4's Nursing Care Plan from 03/20/2021 revealed:
1. P4 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P4 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
H. Record Review of P4's Nursing Assessments from 03/28/2021-04/07/2021 revealed:
1. On 03/28/2021 no documentation of T&P for the entire day.
2. On 03/29/2021 no documentation of bathing for the entire day.
3. On 04/05/2021 no documentation of T&P from 7:00am- 5:00pm.
4. On 04/07/2021 no documentation of T&P from 7:00am- 7:00pm, no documentation of bathing for the entire day.
Patient #5 (P5) findings
I. Record Review of P5's Nursing Care Plan from 01/20/2021 revealed:
1. P5 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P5 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
J. Record Review of P5's Nursing Assessments from 01/25/2021-02/16/2021 revealed:
1. On 01/25/2021 no documentation of T&P from 6:00pm- 6:00am, no documentation of skin care done from 6:00pm- 6:00am
2. On 01/26/2021 no documentation of T&P from 7:00am-6:00pm, no documentation of skin care done from
7:00am- 4:00pm, no documentation of bathing or oral hygiene for the entire day
3. On 01/27/2021 no documentation of T&P from 6:00pm- 6:00am, no documentation of bathing or oral hygiene for the entire day
4. On 01/28/2021 - 02/02/2021 no documentation of bathing or oral hygiene for the entire day
5. On 02/03/2021 no documentation of T&P from 7:00am- 4:00pm, no documentation of oral hygiene for the entire day
6. On 02/09/2021- 02/14/2021 no documentation of bathing or oral hygiene for the entire day
7. On 02/15/2021 and 02/16/2021 no documentation of T&P for the entire day, no documentation of bathing or oral hygiene for the entire day
K.Record Review of P6's Nursing Care Plan from 02/11/2021 revealed:
1.P6 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2.P6 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
L.Record Review of P6's Nursing Assessments from 02/12/2021- 03/05/2021 revealed:
1. On 02/12/2021 and 02/13/2021 no documentation of skin care done from 7:00am- 5:00pm, no documentation of bathing for the entire day
2. On 02/15/2021 and 02/16/2021 no documentation of T&P the entire day
3. On 02/17/2021 and 02/18/2021 no documentation of T&P from 6:00pm- 6:00am, no documentation of bathing for the entire day
4. On 02/21/2021 no documentation of T&P from 7:00am- 6:00pm
5. On 02/25/2021 and 02/26/2021 no documentation of T&P from 7:00am- 5:00pm
6. On 03/04/2021 no documentation of skin care done from 7:00am- 5:00pm, no documentation of bathing during the entire day, no documentation of bathing during the entire day
7. On 03/05/2021 no documentation of skin care done from 6:00pm- 6:00am, no documentation of bathing for the entire day, no documentation of bathing for the entire day
M. Record Review of P7's Plan of Care from 01/21/2021 revealed:
1. P7 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P7 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
N. Record Review of P7's Nursing Assessments from 01/21/2021- 02/24/2021 revealed:
1. On 01/22/2021 no documentation of T&P from 7:00am- 5:00pm
2. On 01/27/2021 no documentation of T&P from 7:00am- 3:00pm, no documentation of skin care done from 7:00am- 5:00pm
3. On 01/28/2021 no documentation of T&P from 7:00am- 5:00pm
4. On 01/29/2021 no documentation of T&P from 7:00am- 5:00pm
5. On 02/02/2021 no documentation n of T&P from 7:00am- 5:00pm, no documentation of bathing for the entire day
6. On 02/03/2021 no documentation of T&P from 10:00am- 7:00pm, no documentation of bathing for the entire day
7. On 02/08/2021 no documentation of T&P from 7:00am- 5:00pm
8. On 02/24/2021 no documentation of T&P from 6:00pm- 6:00am
O. Record Review of P8's Nursing Care Plan from 02/17/2021 revealed:
1. P8 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P8 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
P. Record Review of P8's Nursing Assessment from 02/20/2021- 04/01/2021 revealed:
1. On 02/20/2021 no documentation of T&P from 2:00pm- 6:00am
2. On 02/22/2021 no documentation of T&P from 7:00am- 7:00pm
3. On 02/26/2021 no documentation of skin care done from 7:00pm-6:00am
4. On 03/06/2021 no documentation of T&P from 7:00am- 4:00pm, no documentation of skin care done from 7:00am- 4:00pm
5. On 03/07/2021- 03/11/2021 no documentation of bathing for the entire day
6. On 03/14/2021- 03/16/2021 no documentation of bathing for the entire day
7. On 03/20/2021 no documentation of T&P from 7:00am- 5:00pm, no documentation of skin care from 7:00am- 5:00pm
8. On 03/21/2021-03/26/2021 no documentation of bathing for the entire day
9. On 03/27/2021 no documentation of T&P from 7:00am- 5:00pm
10. On 03/30/2021 no documentation of T&P from 10:00am- 4:00pm
11. On 04/01/2021 no documentation of T&P from 5:00pm- 6:00am, no documentation of skin care done from 5:00pm- 6:00am, no documentation of bathing for the entire day
Q. Record Review of P10's Nursing Care Plan from 03/18/2021 revealed:
1. P10 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P10 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
R. Record Review of P10's Nursing Assessments from 03/22/2021- 04/08/2021
1. On 03/22/2021 no documentation of T&P from 7:00am- 5:00pm, no documentation of bathing for the entire day
2. On 04/02/2021 no documentation of T&P from 7:00am- 5:00pm, no documentation of skin care from 7:00am- 5:00pm
S. Record Review of P11's Nursing Care Plan from 02/09/2021 revealed:
1. P11 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P11 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
T. Record Review of P11's Nursing Assessments from 02/21/2021 revealed:
1. No documentation of skin care done from 7:00am- 5:00pm
U. Record Review of P11's Provider Progress Note from 02/21/2021 revealed:
1. P11 complained to the provider that their call bell never gets answered
V. Record Review of P11's Complaint/Grievance Report from 02/21/2021 revealed:
1. At 6:00am P11 reported that they pushed their call button for the nurse for medication, blanket, and heating pad and received a response "we'll send someone in"
2. At 9:00am P11 reported that a nurse entered her room but not for the needs she requested at 6:00am
3. At 9:48 P11 again pushed her call light for the same needs as at 6:00am
4. At 9:52 am P11 received the response that someone will come in
5. At 11:52am a Patient Care Technician came in but P11 reports they still never received the medication they requested.
6. Corrective Action from facility's investigation: Assignment of a staff member to answer all call lights and communicate patient needs to either a nurse or a patient care technician
W. Record Review of P12's Nursing Care Plan from 01/07/2021 revealed:
1. P12 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P12 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
X. Record Review of P12's Nursing Assessments from 01/07/2021-02/03/2021 revealed:
1. On 01/07/2021-01/10/2021 no documentation of bathing for the entire day
2. On 01/12/2021-01/14/2021 no documentation of bathing for the entire day
3. On 01/17/2021 no documentation of T&P from 7:00am- 6:00pm
4. On 01/19/2021-01/29/2021 no documentation of bathing for the entire day
5. On 02/03/2021 no documentation of skin care and bathing done for the entire day
Y. Record Review of P13's Nursing Care Plan from 12/29/2020 revealed:
1. P13 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P13 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized.
Z. Record Review of P13's Nursing Assessments from 01/06/2021- 02/04/2021
1. On 01/06/2021 no documentation of T&P from 6:00pm- 6:00am, no documentation of skin care done from 6:00pm- 6:00am, no documentation of bathing done for the entire day
2. On 01/07/2021 no documentation of T&P, skin care, or bathing done for the entire day
3. On 01/08/2021- 01/10/2021 no documentation of bathing for the entire day
4. On 01/12/2021 no documentation of T&P from 7:00pm- 6:00am
5. On 01/13/2021 no documentation of T&P from 9:00am- 6:00am
6. On 01/20/2021- 01/24/2021 no documentation of bathing done for the entire day
7. On 01/25/2021 no documentation of T&P from 7:00am- 6:00pm, no documentation of bathing done for the entire day
8. On 01/29/2021 no documentation of skin care done from 7:00am- 6:00pm, no documentation of bathing done for the entire day
9. On 01/30/2021- 02/03/2021 no documentation of skin care done for the entire day
10. On 02/04/2021 no documentation of T&P from 6:00pm- 6:00am
AA. Record Review of P13's Complaint/Grievance Report from 02/14/2021 revealed:
1. Complainant concerned about the hygiene of P13 "I noticed his [P13] eyes had a lot of mucus in the corners and on his eyeball so I cleaned his eyes with my own tissues because there was no tissue box in the room. His body was extremely dry. I asked a tech (PCT) for some lotion and I put it on him. He had used the bathroom, so he had his diaper changed. After he was changed I saw Jevity (feeding tube formula, supplemental nutrition) from his peg (artificial feeding tube in the stomach) all over his gown and diaper. I told his nurse and she saw [noticed] that she forgot to close the tube cap and just wiped him off with a towel and didn't change his gown or diaper. I am very disappointed with the care and because of the careless job of not keeping him clean."
BB. Record Review of P14's Nursing Care Plan from 08/06/2020 revealed:
1. P14 has a nursing diagnosis of self-care deficit related to bathing and it is indicated under interventions that the patient will be encourgaed or assisted with activities of daily living
2. P14 has a nursing diagnosis of high risk for impaired skin integrity and it is indicated under interventions that the patient will be turned and positioned every 2 hours and that the skin will be kept clean, dry, and moisturized
CC. Record Review of P14's Nursing Assessments from 08/07/2020- 09/05/2020 revealed:
1. On 08/07/2020 no documentation of T&P from 8:00am- 6:00pm, no documentation of skin care done from 8:00am- 5:00pm
2. On 08/08/2020 no documentation of T&P from 8:00am- 5:00pm, no documentation of skin care done from 8:00am- 5:00pm
3. On 08/11/2020 no documentation of T&P from 7:00am- 6:00pm, no documentation of skin care done from 8:00am- 6:00pm
4. On 08/13/2020 no documentation of T&P from 8:00pm- 6:00am, no documentation of skin care done from 6:00pm- 6:00am
5. On 08/22/2020 no documentation of T&P from 7:00am- 5:00pm, no documentation of skin care done the entire day
6. On 08/25/2020 no documentation of T&P from 8:00am- 6:00am
7. On 08/26/2020 no documentation of skin care done from 7:00am- 5:00pm
8. On 09/02/2020 no documentation of T&P from 7:00am- 5:00pm
9. On 09/03/2020 no documentation of T&P from 7:00am- 5:00pm, no documentation of skin care done from 7:00am- 5:00pm, no documentation of skin care done the entire day
10. On 09/04/2020 no documentation of T&P from 7:00am- 6:00pm, no documentation of skin care done from 7:00am- 6:00pm, no documentation of skin care done the entire day
11. On 09/05/2020 no documentation of T&P for the entire day, no documentation of skin care done from 7:00am- 5:00pm, no documentation of skin care done the entire day
DD. Record Review of facility's "Turn Teams and Hourly Purposeful Rounding" policy effective since 10/2016 revealed:
1. Turn Teams: each shift the charge nurse will identify the 3 members of the turn team and schedule the rounding for every 2 hours, to reposition patients who are unable to reposition themselves
2. Evidenced based outcomes of turn team process: reduce/prevent hospital acquired wounds and pneumonia (lung infection), improves patient comfort, optimizes teamwork, and reduces patient complaints
EE. Record Review of facility's "Skin Care Protocol" policy effective since 01/2013 revealed:
1. Patients, both at low and high risk for skin breakdown, are to be bathed daily with mild soap, rinse, and dry thoroughly
2. Patients, both at low and high risk for skin breakdown, are to have their skin inspected for signs and symptoms of breakdown at each patient repositioning
3. Patients, both at low and high risk for skin breakdown, are to have an established and recorded turning schedule. Intervals may vary from 15 minutes to 2 hours. Evaluate the skin after each turning interval.
FF. On 04/14/2021 at 11:00am, interview with S9 (Certified Nursing Assistant, CNA) indicated that regarding skin protection and interventions there is an expectation to turn and position patients every 2 hours, but that this can be delayed if the patient care technician (PCT) or CNA is busy with another task. When asked about the bathing routine, S9 confirmed that all patients are bathed every other day in a staggering schedule based on room assignment and that it is noted in a separate shower schedule.
GG. On 04/14/2021 at 11:24am, interview with S8 (PCT) stated that patient hygiene falls on the responsibility of the PCTs and CNAs to complete and that it follows a shower schedule. S8 continued by indicating that the facility has allowed an extra PCT/CNA on for half of a morning shift to assist with bathing as the others can become busy having to do other tasks. Regarding skin interventions, S8 confirms the expectation is to have patients turned and positioned every 2 hours but that it can be delayed due to conflicting duties.
HH. On 04/14/2021 at 12:00pm, interview with S7 (Licensed Practical Nurse, LPN) reinforced that it is the responsibility of the PCTs/CNAs to ensure that patients are turned and positioned every 2 hours, but that it is the responsibility of nursing to ensure that the patient's skin is clean, dry, and intact. S7 also indicated that some nurses do not engage in teamwork or do not assist the PCTs/CNAs in turning patients.
II. On 04/14/2021 at 11:33am, interview with S6 (Registered Nurse, RN) confirmed that turning schedules are the responsibility of the PCTs/CNAs.
JJ. On 04/14/2021 at 1:07pm, interview with S5 (Charge Registered Nurse) explained that the expectation for bedside nurses regarding hygiene is to ensure that their patient's skin is clean, dry, and intact and that their mouth is clean and moist. If hygiene or skin measures are not done by the PCTs/CNAs then the nurse must complete them as they have responsibility to their patient. S5 confirmed that the shower schedule is not part of a patient's medical record, nor does it identify if a specific patient has been bathed. The shower schedule identifies which PCT/CNA bathed a patient based on their room but there is a high amount of changing of patient's room assignments so it's hard to correlate.
KK. On 04/14/2021 at 2:17pm, interview with S4 (Wound Care Registered Nurse) reported that patients are bathed every other day, despite it being in contradiction to facility's policy. S4 confirmed that wound care was not consulted prior to implanting a change in bathing routines.
LL. On 04/14/2021 at 1:35pm, interview with S2 (Chief Clinical Officer) recognized the identified contraindication between the practice of bathing patients every other day and the facility's "Skin Care Protocol" policy stating they are to be bathed daily. S2 reported that all aspects of patient hygiene are the responsibility of all clinical staff and must be done at a minimum of once a day. S2 stated that nursing is expected to assess a patient's skin at a minimum of every 2 hours, in conjunction with turning and positioning. S2 countered that PCTs/CNAs may perform the majority of turning and positioning, but that it is the burden of nursing to ensure that the actions are documented timely and accurately.
SUPERVISION OF CONTRACT STAFF
Tag No.: A0398
Based on record review and interviews the facility failed to provide supervision to ensure compliance of policy and procedures by all licensed staff for 13 (P1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13 and 14) out of 14 patients selected . This failed practice is likely to lead to an increase risk of adverse events, increased length of stay and potential mortality.
The findings are:
A. On 04/14/2021 at 1:35pm, interview with S2 (Chief Clinical Officer) recognized the identified contraindication between the practice of bathing patients every other day and the facility's "Skin Care Protocol" policy stating they are to be bathed daily. S2 reported that all aspects of patient hygiene are the responsibility of all clinical staff and must be done at a minimum of once a day. S2 stated that nursing is expected to assess a patient's skin at a minimum of every 2 hours, in conjunction with turning and positioning. S2 countered that PCTs/CNAs may perform the majority of turning and positioning, but that it is the burden of nursing to ensure that the actions are documented timely and accurately.
B. The record review of facility's "Skin Care Protocol" policy that has been effective since 01/2013 revealed:
1. Patients, both high and low risk for skin breakdown, will be bathed daily with mild soap, rinse, and dry thoroughly.
2. Inspect skin for signs and symptoms of breakdown at each patient repositioning (both high and low risk for skin breakdown); note any changes from the previous assessment on the nurse note.
3. Establish and record an individualized turning schedule if the patient is immobile. Frequency of the position change is titrated for the individual patient. Intervals may vary from 15 minutes to 2 hours. Evaluate the skin after each turning interval; if there is non-blanchable redness, increase the frequency of turning.
C. The record review of facility's "Turn Teams and Hourly Purposeful Rounding" policy that has been effective since 10/2016 revealed:
1. Each shift the Charge Nurse will identify the 3 members of the turn team, Turn and Positioning (P&T) and schedule the rounding for every 2 hours, on either even or odd hours, to reposition the patients who are unable to reposition themselves. The 3-person team is used to prevent: patient injury, skin shearing or breakdown dislodgement of lines/tubes and employee injury.
2. The attending nurse and attending Certified Nurse Assistant/Patient Care Technician (CNA/PCT) will alternately visit the patient and attend to the 5 P's of purposeful rounding (pain, potty, position, placement, and promise .) On day shift, the rounding will occur hourly. On the night shift, the rounding will occur every 2 hours.
3. Position- This is the incorporation of turns every 2 hours for patients requiring assisted turns. Patients not requiring turn team attention will have rounds performed only by the attending nurse or CNA/PCT alternately.
4. Evidence based outcomes of the turn team process: reduce/prevent hospital acquired wounds, reduce/prevent hospital acquired pneumonia, promotion of pulmonary toileting, improves patient comfort, reduces patient complaints, optimizes teamwork, improves customer service and confidence in our care.
D. Record review of P1's daily nursing assessment from 01/06/2021 to 03/05/2021 revealed:
1. On 01/10/2021, no documentation of T&P from 7:00 am-5:00 pm, no hourly round from 6:00 pm-6:00 am. No documentation of bathing or oral care for the entire day.
2. On 01/11/2021, no documentation of T&P documented or skin care for entire day. No documentation of bathing or oral care for the entire day.
3. On 01/12/2021, no documentation of T&P from 7:00 am- 5:00 pm. No documentation of bathing or oral care for the entire day.
4. On 01/13/2021-01/16/2021, No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
5. On 01/17/2021, no documentation of T&P from 6:00 pm- 6:00 am. No documentation of bathing for the entire day.
6. On 01/18/2021, no documentation of T&P from 4:00 pm- 6:00 am. No documentation of bathing for the entire day.
7. On 01/19/2021, no documentation of T&P from 4:00 pm- 6:00 am. No documentation of bathing for the entire day.
8. On 01/20/2021, no documentation of skin care 7:00 am- 5:00 pm. No documentation of bathing or oral care for the entire day.
9. On 01/21/2021, no documentation of T&P from 6:00 pm- 6:00 am. No documentation of bathing or oral care for the entire day.
10. On 01/22/2021, no documentation of skin care 7:00 am- 6:00 pm. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
11. On 01/23/2021-01/24/2021, no documentation of T&P from 4:00 pm- 6:00 am. No documentation of bathing for the entire day.
12. On 01/25/2021, no documentation of T&P and skin care. No documentation of oral care from 7:00 am- 6:00 am.
13. On 01/26/2021, no documentation of skin care 7:00 am-5:00 pm. No documentation of oral care from 7:00 am- 6:00 am.
14. On 01/27/2021, no documentation of skin care 7:00 am-5:00 pm. No documentation of oral care from 7:00 am- 6:00 am.
15. On 01/28/2021-01/31/2021. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
16. On 02/01/2021, no documentation of T&P or skin care from 7:00am- 6:00 pm. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
17. On 02/02/2021, no documentation of T&P or skin care from 7:00am- 6:00 pm. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
18. On 02/03/2021, no documentation of skin care from 7:00am- 6:00 pm. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
19. On 02/04/2021-02/06/2021. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
20. On 02/07/2021, no documentation of skin care from 7:00 am- 5:00 pm. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
21. On 02/08/2021, no documentation of T&P or skin care from 7:00 am- 7:00 pm. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
22. On 02/09/2021, no documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
23. On 02/10/2021-02/12/2021, no documentation of T&P from 6:00 pm-6:00 am. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
24. On 02/13/2021, no documentation of T&P from 6:00 pm-6:00 am. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
25. On 02/14/2021-02/15/2021, no documentation of T&P from 6:00 pm-6:00 am and no documentation of bathing for the entire day.
26. On 02/16/2021, no documentation of T&P from 6:00 pm-6:00 am. No documentation of oral care from 7:00 am- 6:00 am and no documentation of bathing for the entire day.
E. Record review of P2's daily nursing assessment from 03/05/2021 to 03/24/2021 revealed:
1. On 03/05/2021, no documentation of T&P from 7:00 am-11:00 am and no documentation of skin care for the entire day, and no documentation of bathing for the entire day.
2. On 03/12/2021, no documentation of T&P for the entire day and no skin care for the entire day, and no documentation of bathing for the entire day.
3. On 03/13/2021, no documentation of bathing for the entire day.
4. On 03/14/2021, no documentation of T&P from 7:00 am-7:00 pm, and no documentation of bathing for the entire day.
5. On 03/24/2021, no documentation of T&P from 6:00 pm-6:00 am and no documentation of skin care for the entire day.
6. On 03/15/2021, no documentation of bathing for the entire day.
7. On 03/17/2021, no documentation of bathing for the entire day.
8. On 03/23/2021, no documentation of bathing for the entire day.
9. On 03/24/2021, no documentation of bathing for the entire day.
F. Record review of P3's daily nursing assessment from 02/09/2021 to 03/16/2021 revealed:
1. On 02/10/2021, no documentation of bathing for the entire day.
2. On 02/11/2021, no documentation of T&P from 6:00 pm-6:00 am and no documentation of skin care for the entire day, and no documentation of bathing for the entire day.
3. On 02/12/2021-02/14/2021, no documentation of bathing for the entire day.
4. On 02/15/2021, no documentation of T&P from 6:00 pm-6:00 am and no documentation of skin care for the entire day.
5. On 02/16/2021, no documentation of T&P for the entire day, and no documentation of bathing for the entire day.
6. On 02/17/2021, no documentation of T&P from 6:00 pm- 6:00 am, and no documentation of skin care for the entire day, and no documentation of bathing for the entire day.
7. On 02/18/2021, no documentation of T&P from 6:00 pm- 6:00 am.
8. On 02/21/2021, no documentation of T&P from 7:00 am- 5:00 pm.
9. On 02/22/2021, no documentation of T&P from 5:00 pm- 6:00 am, and no documentation of bathing for the entire day.
10. On 02/23/2021-02/24/2021, no documentation of T&P from 6:00 pm- 6:00 am, and no documentation of bathing for the entire day.
11. On 02/25/2021, no documentation of T&P from 6:00 pm- 6:00 am and no documentation of skin care for the entire day, and no documentation of bathing for the entire day.
12. On 02/26/2021-02/27/2021, no documentation of bathing for the entire day.
13. On 03/02/2021, no documentation of T&P from 4:00 pm-6:00 am, and no documentation of skin care from 7:00 pm-6:00 am, no documentation of oral care for the entire day, no documentation of bathing for the entire day.
14. On 03/03/2021, no documentation of T&P from 6:00 pm-6:00 am, and no documentation of skin care from 7:00 pm-6:00 am, no documentation of bathing for the entire day.
15. On 03/04/2021, no documentation of T&P from 6:00 pm-6:00 am, and no documentation of skin care the entire day, no documentation of bathing for the entire day.
16. On 03/05/2021, no documentation of skin care from 7:00 am-5:00 pm, no documentation of bathing for the entire day.
17. On 03/06/2021, no documentation of T&P from 7:00 am-5:00 pm, and no documentation of skin care from 7:00 am- 5:00 pm, no documentation of bathing for the entire day.
18. On 03/09/2021, no documentation of T&P from 6:00 pm-6:00 am, and no documentation of skin care from 6:00 pm- 6:00 am, no documentation of bathing for the entire day.
19. On 03/10/2021-03/13/2021, no documentation of bathing for the entire day.
20. On 03/14/2021, no documentation of T&P from 7:00 am-5:00 pm, no documentation of bathing for the entire day.
21. On 03/16/2021, no documentation of T&P from 6:00 pm-6:00 am.
G. Record review of P4's daily nursing assessment from 03/28/2021 to 04/07/2021 revealed:
1. On 03/28/2021, no documentation of T&P for the entire day.
2. On 03/29/2021, no documentation of skin care or bathing for the entire day.
3. On 03/30/2021, no documentation for oral care for the entire day.
4. On 03/31/2021, no documentation of skin care or bathing for the entire day.
5. On 04/04/2021, no documentation of skin care or bathing for the entire day.
6. On 04/05/2021, no documentation of T&P from 7:00 am-5:00 pm, no documentation of skin care or bathing for the entire day.
7. On 04/07/2021, no documentation of T&P from 7:00 am-7:00 pm, no documentation of skin care or bathing for the entire day.
H. Record review of P5's daily nursing assessment from 01/26/2021 to 02/15/2021 revealed:
1. On 01/25/2021, no documentation of T&P from 6:00 pm- 6:00 am. No documentation of skin care from 6:00 pm- 6:00 am.
2. On 01/26/2021, no documentation of T&P from 7:00 am- 6:00 pm. No documentation of skin care from 7:00 am- 4:00 pm, no documentation of oral care for the entire day, and no documentation of bathing for the entire day.
3. On 01/27/2021, no documentation of T&P from 6:00 pm- 6:00 am, no documentation of oral care for the entire day, and no documentation of bathing for the entire day.
4. On 01/28/2021-01/29/2021, no documentation of oral care for the entire day, no documentation of bathing for the entire day.
5. On 01/30/2021-01/31/2021, no documentation of oral care for the entire day.
6. On 02/01/2021-02/02/2021, no documentation of oral care for the entire day, no documentation for bathing for the entire day.
7. On 02/03/2021, no documentation of T&P from 7:00 am-4:00pm, no documentation of oral care for the entire day.
8. On 02/06/2021-02/07/2021- no documentation of oral care for the entire day.
9. On 02/09/2021-02/14/2021, no documentation of oral care for the entire day, no documentation of bathing for the entire day.
10. On 02/15/2021, no documentation of T&P for the entire day, no documentation of oral care for the entire day, no documentation of bathing for the entire day.
11. On 02/16/2021, no documentation of T&P for the entire day, no documentation of oral care for the entire day, no documentation of bathing for the entire day.
I. Record review of P6's daily nursing assessment from 02/12/2021 to 03/05/2021 revealed:
1. On 02/12/2021, no documentation of skin care from 7:00 am-5:00 pm, no documentation of bathing for the entire day.
2. On 02/13/2021, no documentation of skin care from 7:00 am-5:00 pm, no documentation of bathing for the entire day.
3. On 02/14/2021, no documentation of bathing for the entire day.
4. On 02/15/2021, no documentation of T&P for the entire day, no documentation of bathing for the entire day.
5. On 02/16/2021, no documentation of T&P for the entire day, no documentation of bathing for the entire day.
6. On 02/17/2021, no documentation of T&P from 6:00 pm -6:00 am, no documentation of bathing for the entire day.
7. On 02/18/2021, no documentation of T&P from 6:00 pm -6:00 am
8. On 02/21/2021, no documentation of T&P from 7:00 am -6:00 pm, no documentation of bathing for the entire day.
9. On 02/25/2021, no documentation of T&P from 7:00 am -5:00 pm
10. On 02/26/2021, no documentation of T&P from 7:00 am -5:00 pm
11. On 03/03/2021, no documentation of bathing for the entire day.
12. On 03/04/2021, no documentation of skin care from 7:00 am-5:00 pm, no documentation of bathing for the entire day.
13. On 03/05/2021, no documentation of T&P from 6:00 pm -6:00 am, no documentation of bathing for the entire day.
J. Record review of P7's daily nursing assessment from 01/22/2021 to 02/24/2021 revealed:
1. On 01/22/2021, no documentation of T&P from 7:00 am -5:00 pm
2. On 01/27/2021, no documentation of T&P from 7:00 am -3:00 pm, no documentation of skin care from 7:00am-5:00 pm
3. On 01/28/2021, no documentation of skin care from 7:00 am-5:00 pm
4. On 01/29/2021, no documentation of skin care from 7:00 am-5:00 pm
5. On 02/02/2021, no documentation of T&P from 7:00 am -5:00 pm, no documentation of bathing for the entire day.
6. On 02/03/2021, no documentation of T&P from 10:00 am-7:00 pm, no documentation of bathing for the entire day.
7. On 02/07/2021, no documentation of bathing for the entire day.
8. On 02/08/2021, no documentation of T&P from 7:00 am-5:00 pm
9. On 02/24/2021, no documentation of skin care from 6:00 pm- 6:00 am
K. Record review of P8's daily nursing assessment from 02/20/2021 to 04/01/2021 revealed:
1. On 02/17/2021-02/19/2021, no documentation of bathing for the entire day.
2. On 02/20/2021, no documentation of T&P from 2:00 pm-6:00 am, no documentation of bathing for the entire day.
3. On 02/21/2021, no documentation of bathing for the entire day.
4. On 02/22/2021, no documentation of T&P from 7:00 am-7:00 pm, no documentation of bathing for the entire day.
5. On 02/23/2021, no documentation of bathing for the entire day.
6. On 02/26/2021, no documentation of skin care from 7:00 pm-6:00 am, no documentation of bathing for the entire day.
7. On 02/27/2021, no documentation of bathing for the entire day.
8. On 03/04/2021, no documentation of bathing for the entire day.
9. On 03/06/2021, no documentation of T&P from 7:00 am-4:00 pm, no documentation on skin care from 7:00 am-4:00 pm.
10. On 03/07/2021-03/11/2021, no documentation of bathing for the entire day.
11. On 03/14/2021-03/16/2021, no documentation of bathing for the entire day.
12. On 03/19/2021, no documentation of bathing for the entire day.
13. On 03/20/2021, no documentation of T&P from 7:00 am- 5:00 pm, no documentation of skin care from 7:00 am-5:00 pm
14. On 03/21/2021-03/26/2021, no documentation of bathing for the entire day.
15. On 03/27/2021, no documentation of T&P from 7:00 am- 5:00 pm, no documentation of bathing for the entire day.
16. On 03/28/2021, no documentation of bathing for the entire day.
17. On 03/30/2021, no documentation of T&P from 10:00 am- 4:00 pm
18. On 03/31/2021, no documentation of bathing for the entire day.
19. On 04/01/2021, no documentation of T&P from 5:00 pm- 6:00 am, no documentation of skin care from 5:00 pm-6:00 am, no documentation of bathing for the entire day.
L. Record review of P10's daily nursing assessment from 03/22/2021 to 04/02/2021 revealed:
1. On 03/22/2021, no documentation of T&P for entire day, no documentation of skin care from 7:00 am-5:00 pm, no documentation of bathing for the entire day.
2. On 03/23/2021, no documentation of bathing for the entire day.
3. On 04/02/2021, no documentation of T&P for entire day, no documentation of skin care from 7:00 am-5:00 pm.
M. Record review of P11's daily nursing assessment from 02/21/2021 revealed:
1. On 02/21/2021, no documentation of T&P from 7:00 am- 5:00 pm
A. Record Review of P11's Provider Progress Note from 02/21/2021 revealed:
1. P11 complained to the provider that their call bell never gets answered
B. Record Review of P11's Complaint/Grievance Report from 02/21/2021 revealed:
1. At 6:00am P11 reported that they pushed their call button for the nurse for medication, blanket, and heating pad and received a response "we'll send someone in"
2. At 9:00am P11 reported that a nurse entered her room but not for the needs she requested at 6:00am
3. At 9:48 P11 again pushed her call light for the same needs as at 6:00am
4. At 9:52 am P11 received the response that someone will come in
5. At 11:52am a Patient Care Technician came in but P11 reports they still never received the medication they requested.
6. Corrective Action from facility: Assignment of a staff member to answer all call lights and communicate patient needs to either a nurse or a patient care technician
N. Record review of P12's daily nursing assessment from 01/07/2021 to 02/03/2021 revealed:
1. On 01/07/2021-01/10/2021, no documentation of bathing for the entire day.
2. On 01/12/2021-01/14/2021, no documentation of bathing for the entire day.
3. On 01/17/2021, no documentation of T&P from 7:00 am- 6:00pm
4. On 01/19/2021-01/20/2021, no documentation of bathing for the entire day.
5. On 01/21/2021, no documentation of T&P from 7:00 am- 5:00pm, no documentation of bathing for the entire day.
6. On 01/22/2021-01/23/2021, no documentation of bathing for the entire day.
7. On 01/24/2021, no documentation of T&P from 7:00 am- 6:00pm, no documentation of bathing for the entire day.
8. On 01/25/2021, no documentation of T&P from 7:00 am- 6:00 pm, no documentation of skin care for the entire day.
9. On 01/26/2021-02/02/2021, no documentation of bathing for the entire day.
10.. On 02/03/2021, no documentation of skin care for the entire day, no documentation of bathing for the entire day.
O. Record review of P13's daily nursing assessment from 01/06/2021 to 02/04/2021 revealed:
1. On 01/06/2021, no documentation of T&P from 6:00 pm-6:00 am, no documentation of skin care from 6:00 pm-6:00 am, no documentation of bathing for the entire day.
2. On 01/07/2021, no documentation of T&P for the entire day, no documentation of skin care for the entire day, no documentation of bathing for the entire day.
3. On 01/08/2021-01/10/2021, no documentation of bathing for the entire day.
4. On 01/12/2021, no documentation of T&P from 7:00 pm-6:00 am
5. On 01/13/2021, no documentation of T&P for the entire day, no documentation of bathing for the entire day.
P. Record Review of P13's Complaint/Grievance Report from 02/14/2021 revealed:
1. Complainant concerned about the hygiene of P13 "I noticed his [P13] eyes had a lot of mucus in the corners and on his eyeball, so I cleaned his eyes with my own tissues because there was no tissue box in the room. His body was extremely dry. I asked a tech (PCT) for some lotion and I put it on him. He had used the bathroom, so he had his diaper changed. After he was changed I saw Jevity (feeding tube formula, supplemental nutrition) from his peg (artificial feeding tube in the stomach) all over his gown and diaper. I told his nurse and she saw that she forgot to close the tube cap and just wiped him off with a towel and didn't change his gown or diaper. I am very disappointed with the care and because of the careless job of not keeping him clean."
2. Corrective Action from Facility: Documentation in P13's chart for 02/14/2021 does indicate they received a bed bath as schedules. Facility will reeducate staff on proper oral and eye care during annual skills fair.
6. On 01/17/2021, no documentation of T&P from 7:00 am-6:00 pm, no documentation of bathing for the entire day.
7. On 01/20/2021-01/24/2021, no documentation of bathing for the entire day.
8. On 01/25/2021, no documentation of T&P from 7:00 am-7:00 pm, no documentation of bathing for the entire day.
9. On 01/26/2021, no documentation of bathing for the entire day.
10. On 01/28/2021, no documentation of bathing for the entire day.
11. On 01/29/2021, no documentation of skin care from 7:00am- 6:00 pm, no documentation of bathing for the entire day.
12. On 01/30/2021-02/03/2021, no documentation of bathing for the entire day.
13. On 02/04/2021, no documentation of T&P from 6:00 pm-6:00 am
Q. Record review of P14's daily nursing assessment from 08/07/2020 to 09/05/2020 revealed:
1. On 08/07/2020, no documentation of T&P from 8:00 am-6:00 pm, no documentation for skin care from 8:00 am- 5:00 pm
2. On 08/08/2020, no documentation of T&P from 8:00 am-5:00 pm, no documentation for skin care from 8:00 am- 5:00 pm
3. On 08/12/2021, no documentation of bathing for the entire day.
4. On 08/11/2020, no documentation of T&P from 7:00 am-6:00 pm, no documentation for skin care from 8:00 am- 6:00 pm
5. On 08/13/2020, no documentation of T&P from 8:00 pm-6:00 am, no documentation for skin care from 7:00 pm- 6:00 am
6. On 08/15/2021-08/17/2021, no documentation of bathing for the entire day.
7. On 08/19/2021, no documentation of bathing for the entire day, no documentation of bathing for the entire day.
8. On 08/20/2020, no documentation for skin care for the entire day.
9. On 08/21/2020, no documentation of T&P from 7:00 pm-6:00 am, no documentation for skin care from 6:00 pm- 6:00 am, no documentation of bathing for the entire day.
10. On 08/22/2020, no documentation of T&P from 7:00 am-5:00 pm, no documentation of bathing for the entire day.
11. On 08/25/2020, no documentation of T&P for the entire day.
12. On 08/26/2020, no documentation for skin care from 7:00 am- 5:00 pm, no documentation of bathing for the entire day.
13. On 08/31/2021, no documentation of bathing for the entire day.
14. On 09/02/2020, no documentation of T&P from 7:00 am-5:00 pm.
15. On 09/03/2020, no documentation of T&P from 7:00 am-5:00 pm, no documentation for skin care from 7:00 am- 5:00 pm, no documentation of bathing for the entire day.
16. On 09/04/2020, no documentation of T&P from 7:00 am-6:00 pm, no documentation for skin care from 7:00 am- 6:00 pm, no documentation of bathing for the entire day.
17. On 09/05/2020, no documentation of T&P for the entire day, no documentation for skin care from 7:00 am- 5:00 pm, no documentation of bathing for the entire day.
R. On 04/14/2021 at 11:00am, interview with S9 (Certified Nursing Assistant, CNA) indicated that regarding skin protection and interventions there is an expectation to turn and position patients every 2 hours, but that this can be delayed if the patient care technician (PCT) or CNA is busy with another task. When asked about the bathing routine, S9 confirmed that all patients are bathed every other day in a staggering schedule based on room assignment and that it is noted in a separate shower schedule.
S. On 04/14/2021 at 11:24 am, interview with S8 (PCT) stated that patient hygiene falls on the responsibility of the PCTs and CNAs to complete and that it follows a shower schedule. S8 continued by indicating that the facility has allowed an extra PCT/CNA on for half of a morning shift to assist with bathing as the others can become busy having to do other tasks. Regarding skin interventions, S8 confirms the expectation is to have patients turned and positioned every 2 hours but that it can be delayed due to conflicting duties.
T. On 04/14/2021 at 12:00pm, interview with S7 (Licensed Practical Nurse, LPN) reinforced that it is the responsibility of the PCTs/CNAs to ensure that patients are turned and positioned every 2 hours, but that it is the responsibility of nursing to ensure that the patient's skin is clean, dry, and intact. S7 also indicated that some nurses do not engage in teamwork or do not assist the PCTs/CNAs in turning patients.
U. On 04/14/2021 at 11:33 am, interview with S6 (Registered Nurse, RN) confirmed that turning schedules are the responsibility of the PCTs/CNAs.
V. On 04/14/2021 at 1:07 pm, interview with S5 (Charge Registered Nurse) explained that the expectation for bedside nurses regarding hygiene is to ensure that their patient's skin is clean, dry, and intact and that their mouth is clean and moist. If hygiene or skin measures are not done by the PCTs/CNAs then the nurse must complete them as they have responsibility to their patient. S5 confirmed that the shower schedule is not part of a patient's medical record, nor does it identify if a specific patient has been bathed. The shower schedule identifies which PCT/CNA bathed a patient based on their room but there is a high amount of changing of patient's room assignments so it's hard to correlate.