HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that the patient's right to dignity was met as evidenced by 1 patient not getting shaved for several days (Patient #1) due to the hospital not having razors available out of a total of 5 records reviewed.
Findings:

Review of the hospital policy titled, Patient Rights and Responsibilities, revealed in part that it is the hospitals policy to ensure that patient rights are extended to all patients. Further review of the policy revealed that the hospital staff will
act in the best interest of the patient to ensure their right to be respected as an individual with dignity and unique value.

Review of the medical record for Patient #1 revealed he was admitted to the psychiatric senior care unit on 04/12/19 with diagnoses including depression and confusion. Further review of the record revealed the patient was dependent on staff for ADLs (activities of daily living).

Review of the progress noted dated 04/14/19 at 10:02 p.m. by S4Physician revealed that "today he appears slightly disheveled, not as well groomed but also more slowed".

Review of the progress noted dated 04/17/19 at 11:15 p.m. by S4Physician revealed "poorly groomed gentleman, poorly dressed, disheveled, barely able to be elicited".

Review of the discharge progress noted dated 04/22/19 at 8:28 p.m. by S4Physician revealed in part that "As the senior care unit has recently been completely remodeled to conform with new CMS guidelines, some of the equipment such as razors, etc. had not yet been replaced and could not be found. Therefore (Patient #1) was not shaved for several days." Further review of the note revealed that on the date of discharge, when Patient #1's daughter visited, she was surprised at his appearance and requested the patient to be discharged AMA (against medical advice).

Review of the patient's medical record revealed no documented evidence of daily ADL care, including shaving.

On 06/03/19 at 3:30 p.m., interview with S3Tech revealed that for a period of about two weeks in April 2019, there were no razors in hospital and men had to go without shaving. She further revealed that the nurses were aware of this, and were waiting on the shipment of razors to arrive.

On 06/04/19 at 2:00 p.m., interview with S2RN revealed that there was a period of time during Patient #1's hospital stay that the hospital was out of razors. She further stated that when she returned to work after being off for several days, she observed Patient #1 in need of a shave, but the techs stated that there were none. She further stated that the patient's daughter was upset with the patient's appearance when she came to see him.

On 06/04/19 at 2:45 p.m., interview with S1Nursing Director revealed that she was aware that the hospital was out of razors during Patient #1's stay, but stated that an electric razor was also available. When asked to see the electric razor, S1Nursing Director was unable to locate it. Further interview during this time confirmed that there was no documented evidence in Patient #1's record that daily ADL care had been performed, including shaving.

Based on record review and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by failing to perform an assessment for 1 patient who had bruising to the right eye (Patient #1) in a total sample of 5.
Findings:

Review of an incident report dated 04/20/19 at 2:00 a.m. for Patient #1 revealed the patient was restless, combative, aggressive and trying to get out of bed. The report further stated that the nurse and S4Physician saw the "self-inflicted right eye bruise probably caused from rubbing against bed rails".

Review of the discharge summary dated 04/22/19 conducted by S4Physician revealed the patient had slight ecchymosis under right eye from hitting head against bed rail.

Review of Patient #1's nurses notes from 04/20/19 thru 04/22/19 revealed no documented evidence of an assessment of the patient's right eye bruising.

On 06/03/19 at 1:00 p.m., S1Nursing Director reviewed Patient #1's electronic medical record with the surveyor and confirmed there was no documented nursing assessment of the patient's right eye bruising.