HospitalInspections.org

Based on review of facility policy and procedures, facility documents, medical records and interview with staff (EMP), it was determined nursing failed to ensure that the toileting needs were met for three of three medical records reviewed for patients that required toileting every two hours (MR1, MR2, MR3).

Findings include:

Review of facility policy "Moses Taylor Hospital/Skilled Nursing Facility Department of Nursing Fall Prevention", dated reviewed June 2010 revealed "Fall Risk Level ... 9. To prevent falls for all patients:...g. assist with elimination. ... 10. If the patient is a high risk for falls: ... E. Offer assistance with elimination every two (2) hours and document for all patients who should not ambulate alone. Assist with access to commode for BM's if a foley is present."

Review of the facility document "Nursing Care Flow Sheet" revealed a documentation area for "Toileting every (blank area for how many hours) hrs." with hours designated if patient is toileted. Further review of the facility document revealed another area designated as "SAFE Interventions (Safety Factors; Actions; Family/Patient Education; Environment)" where "assistance with elimination needs every 1 to 2 hours" and "offer toileting prior to administration of pain medications" required documentation.

Review of MR1, MR2, and MR3 revealed no documented evidence of consistent toileting or offers to toilet these elderly patients every two hours.

Interview with EMP1 on June 11, 2010, at approximately 2:30 PM confirmed there was no documented evidence that patients were provided assistance with their elimination needs every one to two hours as required by facility policy.