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SPRINGBROOK HOSPITAL
STAFFING AND DELIVERY OF CARE
Tag No.: A0392
Based on record review and interview the facility failed to ensure adequate nursing to provide 1 patient (#1) of 5, with a shower or clothing changed to accommodate an incontinence episode.
Findings:
Telephone interview with patient #1's spouse on 11/18/10, revealed that they had reported to the staff about the clothing that patient #1 was soaked in urine and she/he had not been showered or had his/her clothes changed on 10/20/10. The spouse also stated that they had spoke with patient #1's nurse and Case Manager on 10/20/2010 and that they had confirmed that patient #1 had been in urine soaked clothing and had not been showered.
Record review of the shower schedule for those showers given to the patients on the Older Adult Unit (OAU) between 10/18/10 and 10/22/10 revealed that patient #1 had not been showered as scheduled by staff. Patient #1 had been admitted on 10/18/10 and discharged on 10/22/10.
Interview was conducted with patient #1's Case Manager on 11/18/10 at 1:30 PM. During this meeting it was revealed that on 10/19/10, she confirmed that patient #1's spouse had stated that the clothing that patient #1 was wearing was soaked in urine and she/he had not been showered or his/her clothes changed since before admission on 10/18/10. The Case Manager stated that she told the nurse on the OAU of this concern by the family member of patient #1's incontinent episode and that the nurse told her that it had already been taken care of. The Case Manager also stated that she did not write an incident report of this concern from the family member or a note regarding the conversation with family member and nursing staff.
Interview on 11/18/10 at 2:00 PM with the Risk Manager, she confirmed that there was not any documentation of an incident report of patient #1's family member complaint that his/her spouse was found in urine soaked clothing during a visit on 10/20/10 or any showers for patient #1 were provided. Therefore, nursing staff had not showered patient #1 or assisted in changing his/her clothes during this incontinent episode that the spouse had found during the visit on 10/20/10.