HospitalInspections.org

Based on interview and record review, the facility failed to ensure that registered nurses supervised and evaluated the nursing care of 1 (P-1) of 10 patients reviewed, resulting in poor hygiene and the potential for adverse outcomes. Findings include:

P-1: This 69-year-old female with diagnoses of stage IV lung cancer with metastasis to bone, asthma, diabetes, fibromyalgia, and hypertension. She was admitted to the facility on 3/6/25 and discharged on 3/15/25.

Record review of nursing ADLs (activities of daily living) indicated routine skin care was provided by the registered nurse on 3/8/25 at 0800 and on 3/14/25 at 0800. "Personal care provided" was documented as self-care/independent on 3/13/25 at 0800 and 2000 and on 3/15/25 at 0800. There was no evidence of skin or personal care provided on the other six days the patient was in the facility.

An interview was conducted with the observation unit manager (Staff F) on 7/1/25 at 1000. Staff F stated the expectation for staff is to offer a daily shower if patient is able. Staff can set up patients with bath basins and use wipes if unable to ambulate to the shower. Staff F acknowledged that bathing/skin care was not documented daily on P-1.