HospitalInspections.org

Based on document review and interview, the Registered Nurse failed to follow the P&P (Policy & Procedure) related to Patient Personal Care for bathing offered daily; in the patients MR (Medical Record), for 1 of 10 MR's reviewed (Patient # 8).

Findings include:

1. Review of established hospital policy titled: "Patient Personal Care", indicated on page 2, under Education, 2nd point; "Bathing/showers will be offered daily", and under General Care, 1st point; "All patients shall be encouraged or assisted in grooming daily or more often as needed". Last revised 1/2020.

2. Review of Patient # 8 MR, indicated the following:
A. Patient admitted to APH # 40 (Acute Psychiatric Hospital) on 2/4/2022.
B. Patient discharged/transferred to AH # 50 (Acute Care Hospital) on 2/8/2022.
C. MR lacked documentation in daily flowsheets and/or daily Nurses notes for hygiene care/bathing, offered or completed; for each of the days patient was an inpatient.

3. In interview on 6/1/2022 at approximately 1:00 pm, and at approximately 1:15 pm, with A # 1 (Corporate Quality & Interim D.O.N. {Director Of Nursing), and A # 4 (Chief Executive Officer) the following was confirmed:
A. MR for Patient # 8, lacked documentation/entries by nursing staff; for daily hygiene care.
B. Patients are to be offered and assisted by staff if needed, for daily hygiene care.
C. Documentation to be entered in MR, if patient refuses daily hygiene; bathing, etc.