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Based on medical record review, interview, revealed that nursing staff failed to have documentation of hygiene needs of care and services for 2 (#1, and #2) of 4 sample patients.

Findings:

1.) Medical record review revealed patient #1 was admitted from an Assisted Living Facility under a Baker Act involuntary examination for attacking staff and residents on 12/19/2014. Was discharged from this facility to an Acute Care Hospital on 12/27/2014 for decreased responsiveness, refused medications, fluids, foods, decreased blood pressure, continued deterioration and dehydration.

On admission resident #1 was documented that she required assistance in all Activities of Daily Living (ADL) including hygiene, has Hypertension, an overactive bladder, urinary incontinence, and a suspected Urinary Tract Infection. Urinary Analysis (UA) ordered by the physician revealed a UTI ( Urinary tract infection), antibiotics were ordered.

Review of the physicians progress note on 12/21/2014 stated that this patient has been refusing her medications, has a UTI, and will not take her antibiotics.

Review of the Nursing 24 hour Progress Note revealed that for patient #1's hygiene needs, it was not documented on the 7:00 PM to 7:00 AM shift that she was assisted or total care by nursing staff on 12/21, 12/22/, 12/23, 12/24, and 12/25/2014. Review of patient #1's record with the Director of Nursing (DON) revealed that the documentation from the 12/21 to 12/25/2014 was not done.

2.) Medical record review revealed patient #2 was admitted from home under a Baker Act involuntary examination for threatening and attacking family members on 12/18/2014, and discharged from this facility on 12/28/2014.

On admission resident #2 was documented that she has a history of Bipolar and had not been taking her medications. Review of the Nursing 24 hour Progress Note revealed that for patient #1's hygiene needs, it was not documented on the 7:00 PM to 7:00 AM shift that she was assisted or total care by nursing staff on 12/26, and 12/27/2014. Review of patient #1's record with the Director of Nursing (DON) revealed that the documentation of the 12/26 to 12/27/2014 was not done.

During an interview with the Director of nursing, on 02/11/2015 at 10:05 AM, stated if the documentation is not there, then the care is not done for both patient's #1 and #2.