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NEURO BEHAVIORAL HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview the registered nurse failed to ensure daily ADL's were documented in one (1) of ten (10) medical record's (MR's) reviewed. (Patient # 10)
Findings include:
1. The hospital policy titled, Patient Personal Care, PolicyStat ID 12197137, indicated all patients should be encouraged or assisted in grooming daily or more often as needed. Oral care would be encouraged. This policy was last revised in 01/2020.
2. Review of patient # 10's MR indicated the Patient Safety Observation Rounds lacked documentation of ADL's (Activity Daily Living-bathing/showering, oral care) offered and/or refused on for the following dates: 11/30/2023, 11/29/2023, 11/27/2023, 11/26/2023, 11/25/2023, 11/23/2023, 11/22/2023, 11/19/2023, and 11/18/2023.
3. In interview on 01/22/2024 with staff member S # 4 (Behavioral Health Assistant), confirmed the patient should be offered a bath/shower daily and it should be documented on the Patient Safety Observation Rounds sheet.