HospitalInspections.org

Based on document review and interview, the facility staff failed to ensure two (2) of four (4) patients, Patient #1 and #2, received care in a safe and respectfully manner. Patient #1 did not receive hygiene until family member brought it to the nursing staff's attention. Patient #2 was placed in lobby with no staff present.

The findings include:

The patient's family reported that Patient #1 was admitted on 7/12/21. Family visited on 7/15/21 and found Patient #1 had dried feces under their nails and on the bed rails and sheet.

Staff Member #8 (Manager of 4 East in the West Wing Tower) was interviewed on 11/3/21 at approximately 1:25 P.M. and stated, "Patient #1 was confused and incontinent. We did have an opportunity to improve Patient #1's care and personal hygiene. There was feces on Patient #1's fingers and under their nails and the bed. We had environmental services come in and clean the room, gave Patient #1 a bath and cleaned under their nails and changed the sheets."

A review of the "As Worked" Schedule from July 13 to 18, 2021 indicated the following:

There were four (4) time periods; 7:00 A.M. to 3:00 P.M., 3:00 P.M. to 7:00 P.M., 7:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M.
Staff Member #8 stated, "Our goal is to have one Charge Nurse and three (3) to four (4) Registered Nurses (RNs) and or Licensed Practical Nurses (LPNs) and two (2) Nursing Care Partners (NCP) for twelve (12) to nineteen (19) patients. We don't always have that due to the nursing shortage."

There was no NCP assigned to Patient #1 on 7/17/21 from 11:00 P.M. to 7/18/21 7:00 A.M.

Review of Patient #1's medical record revealed:
Incontinent care was provided on 7/17/21 at 11:00 P.M., 7/18/21 at 2:32 and 6:33 A.M. Patient #1 was assisted in moving from left to right side at 8:20 P.M. on 7/17/21. There was no other documentation of assisting Patient #1 to move. There was no documentation of any nourishment or fluids being given after 8:30 P.M. on 7/17/21 until 7/18/21 at 9:00 A.M.

On 11/3/21 at approximately 2:00 P.M. Staff Member #2 was asked for a policy related to bathing and hygiene for patients and stated, "I don't think we have a policy related to bathing per se but have one related to catheter care."


Patient #2 was observed in the ED (Emergency Department) on 11/3/21 at approximately 11:15 A.M. with daughter present. Daughter stated, "The care provided on 11/3/21 was really great but if you had been here yesterday (11/2/21), I would not have said the same thing. Yesterday, [Patient #2] was brought in by ambulance because of a fall. After the ED staff treated Patient #2, they placed them in the ED lobby. [Patient #2] had a fractured knee, was in a knee immobilizer and had a walker. They had received morphine. No one called me to let me know what was going on or to come get [Patient #2]. [Patient #2] called me. [Patient #2] has a history of stroke and cardiac problems.

When we arrived to pick up [Patient #2], there was no staff in the lobby only patients. No one came to help get [Patient #2] in the car. It took me and my husband thirty (30) minutes to get [Patient #2] in the car."

A review of Patient #2's medical record confirmed the fractured knee and that 4 mg (milligrams) of morphine sulfate had been given at 12:00 Noon.

Staff Member #5 was informed of the interview with Patient #2's family member immediately after and stated, "I will look into it. That should not have happened."