HospitalInspections.org

Based on staff interview, it was determined the hospital did not assure the Psychiatric Unit (managed by a contracted company) submitted quality indicators and the monitoring outcomes to the hospital wide Quality Assessment Process Improvement Committee to ensure the delivery of care to the psychiatric patient. The failed practice had the potential to affect all eight patients on census and all patients admitted to the Unit. The findings were:

Interview on 03/17/11 at 1400, the Nurse Leader of 3South confirmed the contracted company's Quality Assessment/Process Improvement activities were not reported to the hospital wide Quality Assessment/Process Improvement Committee.

Based on clinical record review and staff interview, it was determined the nursing staff did not document patients' received a bath, shower or oral care for five (#1, #2, #3, #4 and #6) of five active patients and five of five (#8-#12) discharged patients. The failed practice prevented the continuity of patient care. The failed practice affected all eight patients on census and all patients admitted to the Psychiatric Unit. The findings were:

A. Review of the " Patient Care Plan Implementation Phase " for Patient #1-#4, #6 and #8-#12 revealed that baths and showers were not recorded and oral care on the day shift was not recorded.
B. Interview on 03/15/11 at 1450, the interim Nurse Leader was questioned regarding the documentation for showers, etc, she stated in the two and half years she had been here bath/showers have not been recorded. The interim Nurse Leader stated they write down when a patient has a shower on the Shower Log but information did not get put in the clinical record. Review of two most current Shower Log sheets revealed it had a column for the pre-printed room numbers, a column for the patient ' s name, a column for date of last shower, a column for shift (7P or 7A) and a column for signature. There was no consistency of recording showers on the tool which was confirmed by the interim Nurse Leader.