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Based on medical record review and interviews, the hospital failed to consistently document baths for Patient Identifier (PI ) # 1 and Patient Identifier # 2, two of 14 sampled patients.

Findings include:

1. A review of the History and Physical dated 2/13/13 revealed PI # 1 was admitted to the Geriatric Psychiatric Unit on 2/12/13 with diagnoses of Senile Dementia with Psychosis and Rule out Delirium. PI # 1 had become increasingly irritable, labile and agitated with multiple aggressive episodes. PI # has had poor hygiene and was not cooperative with ADL's (activities of daily living) at home. Insight, judgement and cognition were impaired. PI # 1 was alert and oriented to person and place, but not to time and date.

A review of PI # 1's Patient Observation Forms dated "2/11/13" (admission date was 2/12/13) through 2/26/13 revealed only three baths were documented as being given during this fifteen day period. One bath was documented as refused, but no explanation was documented.

During an interview on 5/29/14 at 11:20 AM, the GPU Charge Nurse / Employee Identifier (EI) # 1, said baths are given every other day. The behavioral technicians are responsible for documenting baths. According to the Charge Nurse, "If it's not documented, it's not done."


2. Patient Identifier (PI) # 2 was admitted to the GPU on 5/15/14 with diagnoses to include Major Depressive Disorder, Severe without Psychotic Features.

A review of PI # 2's Patient Observation Forms dated 5/15/13 through 5/28/13 revealed only two baths were documented as being given.