HospitalInspections.org

Based on record review, document review, and interview, it was determined that the facility staff failed to adhere to policy and procedure for completing patients' activities of daily living (daily bathing) for two (2) patients (MR3, MR6).

Findings:

Review of facility document, Clinical Technician Academy Program, under the heading "Definitions", it partly reads: "Clinical Technician Academy- A focused education program attended by all newly hired or transfer team members to the position of: Clin Tech 1, Clin Tech 2, Emergency Medical Technician (EMT), and Nurse Extern during their orientation period that introduces... the philosophy, goals, policies, procedures, role expectations and other factors needed to function in their new role...". Under the heading "Procedure", it partly reads: "Completion Requirements: 1. Mandatory attendance for the entire orientation program. 2. Successful completion of all on-learning modules. 3. Successful return demonstration of learned skills...".

Review of facility document that is an attachment to the aforementioned document, under the heading "Bathing", it partly reads: "This cleansing method to be performed on patients at least once a day...".

Review of facility document, Documentation of Nursing Care Guideline, contained an addendum A titled, Clinical Team Documentation Responsibilities that partly reads: "... II. Clinical Technician I and II / Emergency Medicine Technicians / Paramedics. a. Documents in flowsheet and informs the supervising RN of any changes in the patient's status....".

Review of medical record (MR) 3's admission from August 25, 2025 through September 6, 2025 revealed there was one entry on September 3, 2025 at 12:40 PM, in the flowsheet section titled "Hygiene", indicating bathing was completed.

Review of MR6's admission from August 8, 2025 to August 13, 2025 revealed entries on August 8, 2025 and August 9, 2025 indicating bathing was completed. The next flowsheet entry under hygiene was on August 13, 2025, which indicated showering was completed.

Interview on September 25, 2025 at 10:45 AM, MR12 indicated they had been a patient in the facility for a week. During the admission, MR12 had not taken a shower or been offered wipes for a cloth bath.

Interview on September 25, 2025 at 11:20, employee (EMP) 29 indicated that some of their staff responsibilities include taking patient's vital signs, checking blood sugar levels, and assisting patient's with ambulating to the bathroom. The bed linens are changed every other day unless there is a need to change sooner. Patients receive a cloth bath if they are unable to shower. Staff should offer some type of bathing everyday to the patients.