HospitalInspections.org

Based upon review of 1 of 6 medical records and staff interviews, the hospital failed to ensure the comprehensive treatment plan identified the problem of combative behaviors for patient #5 related to the provision of personal care. This was evidenced by patient #5's combative behaviors when bathing was attempted which resulted in the patient not receiving a bath. Findings:

Review of the medical record for patient #5 revealed the patient was admitted on 07/11/13 for Alzheimer's Dementia, Severe, with Behavioral Disturbances and Intermittent Explosive Disorder. According to the comprehensive treatment plan the problems identified were 1) Cognitive Impairment, 2) Alteration in Health Maintenance, and 3) Increased Risk for Falls.
Interview with S7 Psychiatrist on 08/28/13 at 2:30 p.m. revealed when the staff attempted to provide patient #5 with a shower, she would become physically combative and resist care; however, review of the comprehensive treatment plan revealed this problem was not identified.
Interview on 08/26/13 at 1:05 p.m. with S3 RN, Psychiatric Unit Nurse Manager, revealed the Mental Health Technician (MHT) was responsible for showering each patient on the evening shift and entering this information into the medical record computer system. Interview with S5 MHT on 8/28/13 at 2:20 p.m. confirmed each patient was provided a shower in the evenings.

Review of the MHT's 15 minute observation sheets revealed the only documentation the patient received a shower was on 7/13/13, 7/23/13 and 7/28/13. Patient #5 was discharged on 7/30/13.

Based upon review of medical records, policies and procedures, and staff interview, the hospital failed to ensure active treatment was recorded on each patient's progress notes. This was evidenced by failure to document personal hygiene care (bathing/showering) for 5 of 6 medical records reviewed (#s 1, 2, 3, 4, 5). Findings:

1) Review of Patient #1 ' s medical record revealed, an 84-year-old female admitted, 08/12/2013, with a diagnosis of Depression. Continued review revealed Patient #1 was admit under a Formal Voluntary Admit and had no previous history of psychiatric issues. Her medical history indicated a history of high blood pressure, heart disease, and she was discharged (8/12/13) from the Critical Access Hospital following treatment of hyponatremia (low sodium level in the body). Further review revealed two forms titled " Patient Progress Notes-Vital Signs " and " Patient Progress Notes-Physical Assessment " ..
According to an interview, 08/27/13 at 1:50 p.m. with S4 Registered Nurse (RN), the Mental Health Technician (MHT) would document the patients' vital signs, intake and output, and if the patient received a bed bath or shower on the Patient Progress Notes-Vital Sign form. Review of Patient #1 ' s Patient Progress Notes-Vital Signs form, dated 08/12/13 through 08/28/13 revealed there failed to be documented evidence the MHTs had showered or bathed Patient #1.
Review of Patient #1 ' s Patient Progress Notes-Physical Assessment, dated 08/16/13, revealed S12 RN documented Patient #1 did receive a shower. Continued review revealed S3 RN documented, 08/21/13 at 9:02 a.m, Patient #1 was to receive a shower on the next shift (7P-7A). Further review revealed there failed to be documentation relative to the patient and if she actually received a bed bath or shower. On 08/18/13, 1:58 p.m., S5 MHT (7A-7P) documented "...Shower. Assist. Will be completed on next shift " . Review of documentation for the next shift, 7P-7A, revealed S13 MHT documented " Shower. Had on 08/18/03 " . There failed to be documented evidence Patient #1 received a bath/shower everyday.

2) Review of the medical record for patient #2 revealed a 63 year old male admitted to the hospital on 8/14/13 with the diagnosis Axis I: Bipolar Manic with Psychosis and Axis III: High blood pressure, Diabetes Mellitus, Left inner thigh wound. The patient was admitted under a Physician's Emergency Certificate signed/dated 8/14/13 at 12:00 p.m. with formal voluntary admission signed/dated 8/14/13 at 2:43 p.m. by patient and witnessed by a staff RN and signed/dated by the psychiatrist on 8/15/13 at 3:00 p.m.
Review of electronic ADLs revealed the patient had no bath or shower on 8/2613.
Interview on 8/27/13 at 3:15 p.m. with S5 MHT confirmed the patient did not get a shower and or a bath on 8/26/13.
Interview on 8/27/13 at 3:17 p.m. with S3 RN confirmed after reviewing the electronic ADLs flow sheets for the patient there was no documentation which indicated that the patient had a bath and or a shower on 8/26/13.

3) Review of Patient #3 ' s medical record revealed a 91-year-old male, admitted with diagnosis of Psychotic Behaviors evidenced by seeing children in his room at the nursing home. He was admitted on 07/12/13, under a Formal Voluntary Admit, and discharged 07/19/13. Continued review revealed there failed to be documentation on the Patient Progress Notes-Vital Signs form that the MHT had given Patient #3 a bed bath or shower. Review of Patient Progress Notes-Physical Assessment form revealed S14 RN documented, 07/13/13 at 7:48 p.m., Patient #3 received a shower.

The eight days, 07/12/13 through 07/19/13, Patient #3 was on the Psychiatric Unit; there was 1 day, 07/13/13 at 7:48 p.m., documented that he received a shower/bath. There failed to be documented evidence Patient #3 received a daily shower/bath.

4) Review of Patient #4 ' s medical record revealed a 96-year-old male was admitted under a Non-Contested Admit on 06/13/13 and transferred on 06/20/13, to an Acute Care Hospital. Patient #4's admission diagnosis was Alzheimer's Dementia. Continued medical record review revealed 2 forms titled Patient Progress Notes-Vital Signs and Patient Progress Notes-Physical Assessment. There failed to be documentation on these forms which indicated Patient #4 received a bed bath/shower.

Review of Patient Progress Notes-Physical Assessment, 06/14/13 at 9:15 a.m., revealed S10 RN documented Patient #4 was total care and incontinent of bladder and bowel. Continued review of the form revealed there failed to be documented evidence the patient received a bed bath or shower during his seven day admission.

5) Review of Patient #5's medical record revealed the patient was admitted to the psychiatric unit on 7/11/13 with the diagnoses of Alzheimer's Dementia and confusion and discharged on 7/30/13. Review of the Patient Progress Notes and the 15 minute observations documented by the Mental Health Technicians revealed the only documentation related to the patient receiving a bath or shower was on 7/13/13, 7/23/13, and 7/29/13.

Interview, 08/28/13 at 1:30PM, with S3 RN Psychiatric Unit Manager confirmed patients were to have received a bed bath or shower every day; and this was usually done on the 7P-7A shift and the MHT was to document when it was completed. S3 RN Psychiatric Unit Manager agreed the nurses and/or MHTs should have documented when/or why not the patient received a bath/shower.

Review of policy PC-813 titled Personal Hygiene revealed
"Policy: Patients are responsible for their personal hygiene, including hair care, oral hygiene, and bodily cleanliness. If a patient fails to maintain good personal hygiene due to their functioning level they will be assisted."
"Procedure: 1) Patient's personal hygiene is observed by staff, 2) Patients who fail to maintain appropriate hygiene will be prompted and educated by staff on the importance of personal hygiene, 3) Patients who do not know the proper techniques will be instructed, and 4) Patients who are unable to care for their own personal hygiene will be assisted."