HospitalInspections.org

Based on review of hospital policies/procedures, medical records, staff and patient interviews, it was determined the registered nurse did not consider patients' needs/requirements for personal hygiene, and did not reassess the Emergency Department (ED) patient according to hospital policy, as demonstrated by:

1. failure to offer/provide personal hygiene for 3 of 6 patients (Patients #2, 3, and 22); and

2. failure to re-assess the ED patient, according to policy, for 1 of 1 patients (Patient #21).

Findings include:

1. The hospital policy titled Standards of Nursing Practice and Standards of Patient Care (approved 07/09) requires, "...The patient's personal hygiene needs are met...."

Patient #2, was admitted on 06/06/11, according to the medical record. There was no documentation to conclude personal hygiene was offered or provided, 06/08/11 through 06/13/11. The patient stated during an interview conducted on 06/15/11 at 0915: "...I was offered a shower (on 06/13) but it got too late in the day...(on 06/12) a bed bath would've been nice...." The patient indicated that the staff do not ask if she wants/needs bathing, and do not offer hand cleansers post using the bedside commode.

RN #30, confirmed during an interview and record review conducted on 06/15/11 at 0915, "(hygiene) is offered daily and suppose to be documented in the nurses' notes." RN #30, confirmed there was no documentation the patient was offered/provided personal hygiene for the dates in question.

Patient #3, was admitted on 06/04/11, according to the medical record. There was no documentation to conclude personal hygiene was offered or provided 06/09/11 through 06/14/11. The patient stated during an interview conducted on 06/15/11 at 0930, "...most every day (though not daily) they ask me if I want a shower...."

RN #31, confirmed during an interview and the medical record review conducted on 06/15/11 at 0930, there was no documentation the patient was offered/provided personal hygiene.

Patient #22, was admitted on 12/3/10, according to the medical record. There was no documentation to conclude the patient was offered or provided personal hygiene, 12/03/10 to 12/10/10.

2. The hospital policy titled Standards of Nursing Practice and Standards of Nursing Care requires: "...document the patient's symptoms, responses, and progress...assessment...."

The hospital policy titled Assessment Reassessment of ED patients requires: "...documentation of...vital signs and focused assessment completed initially and reassessment done every 1 hour...."

Patient #21, presented to Emergency Department (ED) on 02/03/11 at 0958, complaining of worsening cough "dispite (sic) antibiotic therapy," according to the medical record. The ED Triage Nurse assessed the patient and assigned the Triage Level/Emergency Severity Index (ESI) 4; (patients with conditions that require medical care, but can be delayed several hours without risk) at 1008. The patient was transferred to ED examination room #6, at 1021, and seen/evaluated by the ED physician at 1025. The patient was discharged at 1240.

The entire ED visit was under 3 hours. The nurses notes section of the ED sheet did not include documentation regarding the following: time; "B/P" (blood pressure); "HR" (heart rate); "RR" (respiratory rate); "Temp" (temperature); "O2 Sat" (oxygen saturation); pain; and the patient's response to respiratory treatments received at 1135 hours and 1150 hours.

The Interim Director of ED RN #11, stated during an interview conducted on 6/15/2011 at 0900, that the Triage RN assigns the ESI level, and patients are reassessed "periodically" based on that level.

The Director of Nursing RN #2, confirmed during an interview and record review conducted on 6/16/11 at 1135, there were no documented required hourly vital signs or reassessment.

Documentation did not demonstrate that the RN assessed, planned, directed and evaluated nursing services provided to ED Patient #21, according to hospital policy.