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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance.

A-0395 - A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document reviews, the facility failed to provide nursing services within recognized standards. Specifically, the facility failed to provide assistance with activities of daily living (ADLs) in four of five medical records reviewed (Patients #1, #3, #4, and #5).

Based on interviews and document reviews, the facility failed to provide nursing services within recognized standards. Specifically, the facility failed to provide assistance with activities of daily living (ADLs) in four of five medical records reviewed (Patients #1, #3, #4, and #5).

Findings include:

Facility policies:

The Routine Bathing policy read, this policy established guidelines for routine patient bathing. Bathing cleans a patient's skin, stimulates circulation, provides mild exercise, and promotes comfort.

The Chlorhexidine (CHG) Bathing policy read, this policy and procedure established guidelines for the reduction of healthcare-associated infections by reducing the bacterial load on the patient's skin. Evidence suggests that daily Chlorhexidine Gluconate (a skin cleanser used to kill germs) bathing may provide clinical benefit when infection rates are high for a given patient population. The patient's plan of care is updated to reflect the CHG bath.

References:

The Lippincott Solutions Procedures online manual (2023), provided by the facility, read, performing a bed bath not only cleans a patient's skin but also stimulates circulation, provides mild exercise, and promotes comfort. It also enables assessment of the condition of the patient's skin as well as joint mobility and muscle strength. Documentation associated with the bed bath includes the date and time of the bed bath and teaching provided to the patient and family. Moreover, soap and water bathing causes skin deterioration in patients who are hospitalized, which can lead to pressure injuries. Daily bathing with chlorhexidine-impregnated disposable cloths can help prevent hospital-acquired infections such as central line-associated bloodstream infections and catheter-associated urinary tract infections.

The facility's bathing order set read, assist with bathing. Start today, three times per week.

The facility's central line (a catheter used to access large veins in the chest)-associated bloodstream infection (CLABSI) order set read, implement CLABSI bundle (a group of tasks done to help prevent infection for central lines): chlorhexidine bath daily, document peripherally interested central catheter (PICC) line (a type of central line) necessity, document central line necessity.

1. The facility failed to ensure patients received baths in accordance with the facility's expectations of baths ordered upon patient's admission.

A. Record review

i. Patient #1's medical record was reviewed. Patient #1 was admitted to the facility on 8/17/23 for acute and chronic respiratory failure. Patient #1 had a tracheostomy (a hole in the windpipe to assist with breathing), a colostomy (an artificial opening in the abdomen for the intestine to empty stool into a bag), and multiple open wounds on his hands, feet, and body caused from poor circulation. Additionally, Patient #1 had a PICC line used for antibiotic therapy. The medical record review for Patient #1 revealed no evidence of a bath for the first 12 days of his admission. Additionally, the medical record reviewed revealed no evidence of a physician's order for bathing until 8/28/23. Furthermore, the medical record review revealed no evidence of a CLABSI bundle order set which resulted in Patient #1 not receiving a daily CHG bath.

ii. Patient #3's medical record was reviewed. Patient #3 was admitted to the facility on 7/18/23 with acute and chronic respiratory failure. Patient #3 had a tracheostomy, a percutaneous endoscopic gastrostomy (PEG) tube (a tube placed into the stomach for the purpose of giving the patient liquid nutrition and medication), and wounds on his abdomen and hips. The medical record review for Patient #3 revealed a written physician's order on 7/20/23 to assist with bathing three days per week. Patient #3's medical record review revealed staff bathed Patient #3 on 8/2/23 and not again until 8/10/23. Additionally, staff bathed Patient #3 on 8/12/23, and not again until 8/17/23. There was no documentation that Patient #3 refused the baths during this time. Furthermore, the medical record review revealed Patient #3 received one bath during the week of 9/4/23. Patient #3 refused one bath the week of 9/4/23, however, there was no evidence of a bath or further refusal from Patient #3 during that week.

This was in contrast to the physician's order which instructed to assist with bathing three times a week.

iii. Patient #4's medical record was reviewed. Patient #4 was admitted to the facility on 3/8/23 for treatment of wounds to her legs and chest. Patient #4's medical record review revealed no physician order for bathing until 4/8/23. Patient #4's bathing order read, assist with bathing three times per week. Patient #4's medical review revealed no evidence of a bath given for the weeks of 3/12/23, 3/19/23, and 3/26/23. The first evidence of Patient #4 receiving a bath was on 4/8/23. Furthermore, Patient #4 did not receive three baths for the weeks of 8/6/23, 8/13/23, and 8/20/23. Additionally, Patient #4 refused her baths for the weeks of 9/3/23, 9/10/23, and 9/17/23 and the medical record review revealed no evidence of why the patient refused or if alternative means of hygiene were offered to the patient during the three weeks she refused the baths.

iv. Patient #5's medical record was reviewed. Patient #5 was admitted to the facility on 4/22/23 with acute respiratory failure, tracheostomy, and wounds to her neck and buttocks. Patient #5's medical record review revealed no physician order for bathing until 5/14/23. Patient #5's medical record review revealed staff gave her a bath on 4/24/23 and then not again until 5/2/23. Additionally, Patient #5 received a bath on 5/3/23, and then not again until 5/13/23. Patient #5's medical record review revealed no evidence staff offered her a third bath during the week of 9/10/23, 9/24/23, or 10/1/23.

B. Interviews

i. On 10/16/23 at 1:45 p.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated the nursing house supervisors completed the patient bath schedule daily and posted the schedule on the units each shift. RN #1 stated the certified nursing assistants (CNAs) then received their assignments which included those patients assigned to get a bath. RN #1 stated the nursing house supervisors ensured the bathing schedule included patient baths three days each week.

ii. On 10/16/23 at 2:14 p.m., an interview was conducted with Patient #4. Patient #4 stated staff members gave her baths three times each week. However, Patient #4 further stated staff could not give her a bath a couple of times because they did not have enough time.

iii. On 10/17/23 at 2:40 p.m., an interview was conducted with certified nursing assistant (CNA) #5. CNA #5 stated she knew which patients received baths based on the printed paper schedule posted on the units each morning. CNA #5 stated it was the responsibility of the CNAs to do the baths and CNAs worked together with RNs for bathing patients. CNA #5 stated she documented baths and any patient refusals on the electronic health record. CNA #5 stated when patients refused a bath, staff offered patients additional times for bathing. CNA #5 stated baths were important because patients became soiled in bed and risked getting infections when they did not bathe regularly. Additionally, CNA #5 stated she gave CHG baths to patients who had Foley catheters (a tube inserted into the bladder to drain urine into a bag) and intravenous (IV) catheters (tubes inserted into veins to give patients medications).

iv. On 10/17/23 at 3:10 p.m., an interview was conducted with RN #2. RN #2 stated patient baths were on a schedule that nursing supervisors created every day. RN #2 stated she was not aware of any bathing orders or documentation requirements in the electronic medical record (EMR). RN #2 stated the RN ultimately had the responsibility to either bathe the patient or ensure the CNA bathed the patient. RN #2 was unaware of the CLABSI order bundles requiring daily CHG baths for patients with central lines. RN #2 stated she preferred using soap and water to bathe all her patients regardless of the patient's type of intravenous access.

v. On 10/17/23 at 4:33 p.m., an interview was conducted with nursing supervisor (Supervisor) #3. Supervisor #3 stated supervisors entered the patient's bathing schedule into the patient's electronic record care plan within 24 hours of admission. Supervisor #3 stated staff updated the patient care plans later than 24 hours if the supervisors were too busy to complete entering the bathing schedule in the patient's record at the time of admission. Supervisor #3 stated supervisors audited the care plans to ensure patients had scheduled baths. Supervisor #3 stated CHG baths showed up in the medical record as a cleanse, not a bath, and staff performed CHG cleanses twice a shift, or, four times a day. Supervisor #3 stated any patient with an invasive line was expected to receive the CHG cleanses.

vi. On 10/18/23 at 11:02 a.m., an interview was conducted with nursing supervisor (Supervisor) #4. Supervisor #4 stated the expectation for bathing frequency was three times a week and staff documented the bath or the patient's refusal of the bath. Supervisor #4 stated the process began at the patient's admission and the primary admitting nurse completed the order entry for the type of bath the patient received. Supervisor #4 stated the supervisors then updated the patient's care plan. Supervisor #4 stated staff were expected to perform CHG baths twice each shift for patients with Foley catheters and central lines.

Supervisor #4 stated she placed the bathing order for Patient #1 on 8/29/23. When asked about the order being placed 12 days after admission, Supervisor #4 stated this was due to human error and did not follow the standard of placing the bathing order at the time of admission.

vii. On 10/17/23 at 3:51 p.m., a request was made to the director of quality management (Director) #6 for policies that outlined the need for physician orders for bathing patients, including the frequency of bathing. The request included a policy that provided guidance and frequency for CHG baths, including which patients required a CHG bath. Director #6 stated there were no policies with these details, therefore the facility was unable to provide policies that included guidance on the frequency and type of bathing.

The lack of clarification in a policy regarding bathing and the use of CHG potentially contributed to the inconsistent understanding staff expressed regarding the bathing process during the interviews.

viii. On 10/18/23 at 2:16 p.m., an interview was conducted with the director of respiratory therapy (Director) #7. Director #7 stated the facility identified an issue with patient bathing approximately six months prior and implemented a process of placing orders at the time of admission for bathing patients. This order then flowed to the task list of the CNAs for bathing patients.

Despite this implementation, staff continued to miss patient baths. This was evidenced by the medical records reviewed that lacked evidence of bathing orders entered at admission or baths being conducted in accordance with physician orders and Supervisor #4's expectations.