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Based on interviews and record review, the facility failed to ensure a bed-fast (unable to move out of bed without assistance) patient was provided a bath and was turned every two hours in one of four medical records reviewed (Patient #1).

Findings include:

Facility policy:

According to the Guidelines for Nursing Care policy, the following basic nursing tasks designated the minimum frequency with which the tasks must be performed: hygiene, if no contraindication, bath/shower every other day and as per patient request. Activity and mobility: bedfast patient turned and documented every two hours and as needed.

1. The facility failed to ensure a bed-fast patient was bathed and repositioned in a manner consistent with facility policy and procedures.

a. Review of Patient #1's record revealed the patient was admitted to the facility on 9/16/22 with a diagnosis of spinal cord injury, new triplegia (a medical condition in which three limbs were paralyzed) and respiratory failure.

i. On 9/21/22, a bath was documented for Patient #1 on the bedside clinical care record. The next bath was not documented until six days later, on 9/27/22. There was no evidence in the medical record Patient #1 was offered or provided a bath or shower during the six day span.

ii. On 9/24/22, reposition turns were documented on the bedside clinical care record for Patient #1 at 7:00 a.m., 9:00 a.m., 10:00 a.m., 12:00 p.m., and 2:00 p.m. The next turn was not documented until five hours later, at 7:00 p.m. On 9/25/22, reposition turns were documented for Patient #1 at 7:00 a.m., 8:00 a.m., and 10:00 a.m. The next turn was not documented until five hours later, at 3:00 p.m. The next reposition after 3:00 p.m. was not documented until 7:00 p.m., four hours later. There was no evidence in the medical record that turning, repositioning or sitting up in a chair was offered or provided to Patient #1 between these times.

This was in contrast with the Guidelines for Nursing Care policy, which instructed staff to turn bed-fast patients at least every two hours.

b. On 11/7/22 at 10:36 a.m., an interview was conducted with certified nurses aid (CNA) #1. CNA #1 stated patients were expected to be offered a bath or shower every other day and more often depending on the patient's needs or requests. She further stated it was important to ensure patients were clean and dry in order to prevent skin breakdown. CNA #1 stated patients were expected to be turned or repositioned every two hours. She stated turning and repositioning was important to do regularly in order to take pressure off of the patient's bony prominences (areas of bone that are close to the skin's surface) and any existing wounds.

c. On 11/7/22 at 11:39 a.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated patients on the medical-surgical units were expected to be bathed every other day. She further stated patients were expected to be turned every two hours or more frequently if needed. She stated the importance of bathing and turning patients regularly was to prevent skin breakdown.

d. On 11/8/22 at 12:42 p.m., an interview was conducted with CNA #3. CNA #3 stated bathing or showering was expected to be done at least every other day in the medical-surgical units, and more often based on the patient's needs. CNA #3 stated patients were expected to be turned or repositioned every two hours, or more often if the patient was uncomfortable. She stated patients may also be turned more frequently if it was time for the patient to be bathed or cleaned up after a bowel movement. She stated the importance of bathing patients on a regular basis was to prevent infection. She further stated the importance of turning patients every two hours was to promote comfort for the patient and to prevent bedsores. CNA #3 stated bedsores could lead to skin breakdown and increase the infection risk for patients.

CNA #3 stated she recalled caring for Patient #1 during his hospitalization. Upon review of Patient #1's bedside clinical care record and nursing notes on the dates of 9/24/22 and 9/25/22, CNA #3 recalled she had taken care of Patient #1 during the day shift on these dates. She stated she did not recall if she had given the patient a bath during these dates or recall when Patient's #1 last had a bath. CNA #3 stated she did not recall why there were no turns documented on Patient #1 during those gaps of time on the dates of 9/24/22 and 9/25/22. She further stated if the family had been at the bedside or if the patient had refused a bath or turn, her practice was to document the refusal in the medical record.

There was no evidence in the medical record Patient #1 had declined turns during those times on 9/24/22 and 9/25/22 or had declined bathing during the span of six days.

e. On 11/8/22 at 2:06 p.m., an interview was conducted with RN #4. RN #4 stated bathing was expected to be done for patients on the medical-surgical unit every other day or about two to three times per week. RN #4 stated it was important to ensure patient's were bathed and clean and dry because there was a risk of infection to the patient if regular bathing was not done. She further stated, bathing was also important for a patient's sense of self-worth.

Upon review of the bedside clinical record, RN #4 stated she had not taken care of Patient #1 on the dates of 9/24/22 and 9/25/22. She stated she was not aware of why there were gaps between documented reposition turns on those dates, but Patient #1 would have been expected to be turned every two hours. She further stated she was not aware of why Patient #1 did not have any documented baths for a span of six days. She stated patients should receive a bath at least every other day.