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Based on interview and record review during an abbreviated survey, it was determined that, the facility medical staff had not entered sufficient information for one of eleven medical records reviewed. Specifically, a patient's medical record was found to be incomplete, lacking documentation of a patient condition. (Patient identifier: 1.)

Findings include:

A review of patient 1's medical record was completed on 2/25/2015. The review of the medical record revealed that patient 1 had been seen in the hospital emergency room on 1/9/2015 for complaints of severe constipation and back pain that radiated down her left leg. The emergency room physician began treatment for patient 1's constipation and did a laboratory work up and X-rays of patient 1's spine. After the full assessment by the emergency room physician, it was determined that patient 1 had a fracture in her spine. The physician had patient 1 admitted for observation only.

Patient 1 was placed on the seventh floor, the trauma floor, and a Neurologic consult had been ordered by the admitting physician. The consultation was completed and the neurosurgeon determined that the best course of treatment for patient 1 was to provide her with a back brace to help support her back and hopefully relieve some pain. The surgeon had also ordered physical therapy and occupational therapy for patient 1.

An interview was held with the hospital's risk manager on 2/25/2015, who had been assisting with patient 1's discharge and had been involved in investigating patient 1's stay in the hospital. The risk manager stated that patient 1 had been discharged from the hospital on 1/12/2015 in the morning. She stated that patient 1's family had requested that patient 1 be given a shower prior to her going home. Patient 1 had been assigned to a male nursing assistant and preferred not to be showered by him. Another female nursing assistant working the floor that day was asked to provide patient 1 a shower. The female nursing assistant was unable to shower patient 1 until late afternoon on 1/12/2015. Patient 1 was assisted into the shower area and provided with the equipment necessary to complete her shower, and the female nursing assistant instructed patient 1 to turn on the call light when she was finished and she would come and assist patient 1 to get dressed. When patient 1 activated the call light, the female nursing assistant did not answer the call light for a documented 6 1/2 minutes. When the female nursing assistant approached the shower room, she could see patient 1 standing in the door way. Patient 1 had propped the door open with a trash can. The female nursing nursing assistant dressed patient 1 in a hospital gown, and walked her back to her room. As the nursing assistant was taking patient 1 back to her room she noticed some reddened areas on patient 1's shoulders and down the middle of her back. The nursing assistant stopped at the nurses station and showed the areas to the registered nurse taking care of patient 1 that day. Patient 1 had stated to the nursing assistant that the pressure from the shower had caused the red areas. As soon as patient 1 was returned to her room, her family immediately took her home.

An interview was conducted with the female nursing assistant that had assisted patient 1 to shower on 2/25/2015. The nursing assistant stated that she had taken patient 1 to the shower room and set the equipment up for her to shower. She stated that she instructed patient 1 to turn on the call light when she was finished and she would come help her get dressed. The nursing assistant stated that when she went to answer the call light, patient 1 had propped the door to the shower room open with a trash can. The nursing assistant stated that patient 1 did not have on any clothes and the expression on her face appeared frightened. The nursing assistant then helped patient 1 to put on a gown. The nursing assistant stated that she noticed reddened areas on patient 1's shoulders and back and asked her if the water had been to hot. Patient 1 replied that the temperature had been fine but the water pressure was too great. The nursing assistant stated that she stopped by the nursing station and showed the charge nurse patient 1's back, then preceded to take patient 1 back to her room. The nursing assistant stated that patient 1's family refused to have her assist patient 1 to get dressed. The family dressed patient 1 and left.

An interview was conducted with the registered nurse (RN) on 2/25/2015, who had been assigned to patient 1 on 1/12/2015. The RN stated that the nursing assistant had asked her to observe patient 1's back. The RN stated that she did look at patient 1's back. She reported she had seen flat reddened purplish areas across her shoulders and back. The RN was asked if she had charted anything about patient 1's back and shoulders. She stated, "No," but that she should have.

On 1/12/2015, patient 1 had been seen by a Nurse practitioner and had written a discharge order for patient 1 to go home with home health. Patient 1 had received the ordered treatment and care. However, the shower and the events that had followed, were not documented in the patient 1's medical record. Patient 1's family had contacted the hospitals patient advocate, and had reported the incident. The patient advocate did an investigation and discovered what had occurred on the evening patient 1 had been discharged.

There was no documentation in the medial record regarding the incident in the shower and the associated care and treatment that followed. There was no record of an assessment of the patient's skin condition or follow up by hospital staff. There was no record of the incident or patient condition in the patient record at all. All information obtained came through interview and documentation that was not part of the patient record.