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Based on document review and interview, facility nursing staff failed to bathe a patient daily, failed to document completed or refused daily bathing and failed to complete and document twice daily dressing changes as ordered by physician for 1 of 10 medical records reviewed. (P1)

Findings include:

1. The facility policy titled, "Standard of Care for the Adult Medical Surgical Patient Guideline", PolicyStat ID 14245172, last revised 9/12/2023, indicated under: Routine Interventions and Reassessment Standards for Medical Surgical Patient: 19. For all MS patients, bathing supplies are to be offered if ambulatory or a bath provided once daily and PRN. Document when completed or "if patient refuses or declines." Refer to facility level policy.

2. The facility policy titled, "Skin Assessment and Management Procedure", PolicyStat ID 14879041, last revised 2/5/2024, indicated under Documentation: Document all skin assessments/interventions on electronic/paper/unit specific flowsheet. Epic documentation should follow the identified format: A. Admission skin assessment and management documentation will include: 5. The following categories should be documented for each Wound LDA: b. Wound Assessments Elements to be documented (as applicable): 19. Dressing changed.

3. Review of MR for P1 indicated a prior order dated 7/18/24 at 5:42 pm indicated P1 was to receive twice daily dressing changes to his/her left inner elbow. Provider order dated 7/19/24 at 1:33 pm indicated P1 was to receive twice daily dressing changes to wounds on his/her right Achilles, right posterior calf, and right posterior ankle. P1's MR lacked documentation of a second dressing change to the left inner elbow, right Achilles, right posterior calf, and right posterior ankle for dates 7/19/24-7/24/24. MR documentation for P1 lacked documented completed bath or refusal for dates 7/20/24, 7/21/24, 7/23/24, and 7/24/24.

4. In interview on 9/3/24 at approximately 1:15 pm with A5 (Nurse Manager) confirmed P1 should have been, but was not offered a bath daily/bathed daily nor were baths charted as completed or refused on 7/20/24, 7/21/24, 7/23/24 and 7/24/24 and should have been. A5 confirmed dressing changes to P1's left inner elbow, right posterior calf, right Achilles, and right ankle should have been completed twice daily but were not.