HospitalInspections.org

Based on document review and interview nursing staff failed to document bathing, linen changes, and physician notification for 1 of 10 patients. (P10)


Findings Include:

1. Facility policy titled, "Chlorhexidine Gluconate Bathing", no policy number, publication date 12/01/2022, indicated a daily Chlorhexidine Gluconate bathing treatment was given to all adult patients in participating units unless contraindicated and to document the CHG treatment in the medical record.

2. Review of P10's medical record (MR) indicated the following:
A. Order written on 10/25/23 at 11:59 am indicated the physician was to be called if the systolic blood pressure (SBP) was below 90 mmhg (millimeters of mercury) and/or a temperature above 38.6 degrees Celsius (C).
B. MR for P10 had a recorded temperature of 38.8 C at 2:59 am on 10/29/23, 39.2 C at 8:02 pm on 10/30/23, and a SBP of 87 at 4:00 am on 11/1/23.
C. MR for P10 lacked documentation of the physician notification per order for systolic blood pressure (SBP) below 90 mmhg (millimeters of mercury) and/or a temperature above 38.6 degrees Celsius (C).
D. MR for P10 lacked of documentation patient bathing on 10/25/23, 10/27/23 and 10/29/23.
E. MR for P10 lacked of documentation linen changes on 10/27/23, 10/29/23, and 10/31/23.

3. In interview on 12/4/23 at approximately 4:30 pm with staff member A10 (Nurse Manager) indicated CHG bathing/ baths and linen changes are to be completed daily.

4. In interview on 12/4/23 at approximately 4:35 pm with staff member A3 (Clinical Nurse Specialist) indicated CHG bathing/baths and linen changes should have been completed daily for this patient and were not.

5. In interview on 12/4/23 at approximately 11:20 pm with staff member A4 (Clinical Nurse Specialist) confirmed there was no nursing documentation that a physician had been called for the P10's temperature of 38.8 C at 2:59 am on 10/29/23, 39.2 C at 8:02 pm on 10/30/23, and a SBP of 87 at 4:00 am on 11/1/23.

Based on document review and interview the facility failed to document daily room cleaning for 9 of 9 days.


Findings Include:

1. Facility policy titled, "Procedure : Daily Cleaning Order", PolicyStat ID 8741500, last revised 10/28/2020, indicated all patient rooms, whether isolation rooms or not, should be cleaned following the standard precautions. Order of Cleaning: Interact/Empty Trash/Linen, Dust with damp microfiber cloth, Clean and Disinfect, Bathroom, Floor, and Inspection. This policy was in effect on P10's dates of stay 10/25/23-10/28/23. There was no new policy for P10's dates of stay 10/29/23-11/2/23.

2. In Interview on 12/18/23 at 9:18 am with A1 (Manager of Accreditation and Regulatory) indicated there were no logs kept showing daily room cleaning for P 10 on dates 10/25/23- 11/2/23.

3. In Interview on 12/22/23 at approximately 11:50 am with A11 (EVS Director) confirmed each employee should turn in a completed checksheet at the end of each shift, there have been no changes or updates to the facility policy titled, "Procedure : Daily Cleaning Order", but the date needs to be renewed, and he/she does not have completed checklists available and/or ready for P10's hospital length of stay.