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A. Based on document review and interview, it was determined in 1 of 1 (Pt #1's) medical record reviewed the Hospital failed to ensure bowel movements were monitored resulting in constipation/fecal impaction. This has the potential to affect all patients receiving care in the Behavioral Health Unit with an average daily census of 12.

Findings include:

1. The medical record of Pt #1 was reviewed on 9/28/2021- 9/29/2021. Pt #1 was admitted to the Behavioral Health Unit on 9/4/2021 with a diagnosis of acute psychosis-danger to self and family. On admission 9/4/2021 Pt #1's record indicated the last bowel movement was 9/3/2021. The "Progress Notes" written by registered nurse (RN-E#3) on 9/7/21 at 11:15 AM indicated, Pt #1 complained of constipation and had "blood streaked feces on right hand, small amount of blood around rectum and in toilet. Rectum bulging with hard feces". On 9/7/21 at 11:36 AM, the nurse practitioner ordered a soap suds enema, administered at 3:30 PM with "substantial amount of hard brown stool eliminated".. The next documented bowel movement was on 9/13/21 at 9:48 AM, small amount of hard formed brown stool A review of the flowsheets indicated bowel movements were not assessed or monitored from 9/3/2021 to 9/6/2021 and 9/8/2021 to 9/13/2021.

2. On 9/29/2021 at approximately 10:00 AM, an interview was conducted the the Director of Behavioral Health (E #1). E #1 stated that "we do not have a policy regarding monitoring bowel movements. We follow the Mosby Fundamental's of Nursing but now realize we must first determine the patient's normal bowel pattern, which we failed to address."

B. Based on document review and interview, it was determined in 3 of 4 (Pt #1, Pt #2 and Pt #3) medical records reviewed the Hospital failed to ensue bathing was offered as required by Mosby Guidance. This has the potential to affect all patients receiving care in the Behavioral Health Unit with an average daily census of 12.

Findings:

1. The medical record of Pt #1 was reviewed on 9/28/2021- 9/29/2021. Pt #1 was admitted to the Behavioral Health Unit on 9/4/2021 with a diagnosis of acute psychosis-danger to self and family. Pt #1's flow sheets indicated Pt #1 received a shower on 9/5/2021 and 9/14/2021. There was no documentation to indicated a shower was offered or declined 9/6/2021 to 9/13/2021, 9/15/2021 and day of discharge 9/16/2021.

2. The medical record of Pt #2 was reviewed on 9/28/2021. Pt #2 was admitted to the Behavioral Health Unit on 9/20/2021 thru 9/27/2021 with a diagnosis of Major Depressive Disorder. Pt #2;s flow sheets lacked documentation on 9/25/2021 that a shower was offered or declined.

3. The medical record of Pt #3 was reviewed on 9/28/2021. Pt #3 was admitted to the Behavioral Health Unit on 9/19/2021- 9/24/2021 with the diagnosis of Depression. Pt #3's flow sheets lacked documentation on 9/22/2021 and 9/23/2021 that a shower was offered or declined.

4. On 9/29/2021 at approximately 9:00 AM, the "Mosby Reference Guide; Mosby Fundamental's of Nursing 2018", was reviewed on 9/28/2021. The docuekmnt required that: "Bathing: Tub and Shower: indicated "the skin should be cleansed once daily".

5. On 9/29/2021 at approximately 10:00 AM, an interview was conducted with the Director of Mental Health (E #1). E #1 stated that, we do not have a policy on bathing but we follow the Mosby Guidance. Our standard of practice is to offer a shower every day, if the shower is refused it should be charted as refused and the register nurse is to be notified.

C. Based on document review and interview, it was determined in 1 of 10 (Pt #1) medical records reviewed the Hospital failed to ensure wound assessment, wound interventions, and wound care to promote the healing process. This has the potential to affect all patients receiving care in the Behavioral Health Unit with an average daily census of 12.

Findings include:

1. The medical record of Pt #1 was reviewed on 9/28/2021- 9/29/2021. Pt #1 was admitted to the Behavioral Health Unit on 9/4/2021 with a diagnosis of acute psychosis-danger to self and family. The initial admitting documentation on 9/4/2021 at 2:54 AM indicated a small healing wound on left heel. On 9/4/21 at 2:54 AM, Pt #1 was given a Braden (skin assessment) score of 21 (score of 19 or greater is at risk for skin issues). Pt #1's medical record lack documentation of wound assessment for 12 shift's from 9/5/2021- 9/16/2021. The record lacked any documentation of wound care or wound interventions, which were provided to Pt #1 during the hospital stay. Pt #1 was discharged on 9/16/2021 and a wound assessment was not performed at discharge. The record lacked documentation for wound care discharge.

2. The Hospital policy titled "Skin Care for Adults" was reviewed 9/29/2021 at approximately 1:00 PM. The policy indicated on page 2 "B. Assessment of all wounds will be completed every shift, including status/integrity of dressing if present, observation for changes in drainage, foul odor, and tissue necrosis...III. Planning/Intervention. B. For patients with...altered skin integrity B. Initiate treatment portion of the SSM Health System Initial Nursing Treatment for Altered Skin Integrity System-Wide Algorithm... c. Consider utilizing the Skin Care Standing Order Set to initiate treatment based on skin assessment." "

3. On 9/29/2021 at approximately 2:00 PM, an interview was conducted with the Behavioral Health Director (E #1).
E #1 reviewed Pt #1's medical record and agreed the medical record lacked documentation for the 12 shift's and a Plan of Care was not initiated for the wound. E #1 stated that "we are in the process of educating staff on skin assessment and care and once complete will start tracking for compliance

4. On 9/29/2021 at approximately 2:30 PM an interview was conducted with the Registered Nurse (E #4) responsible for discharging Pt #1 on 9/16/2021. E #4 reviewed Pt #1's medical record and agreed a wound assessment was not completed on the day of discharge. Pt #1 stated "I was not aware there was a wound. At that time (9/16/2021) we were not required to do a head to toe assessment daily on discharge."

Based on document review and interview, it was determined in 1 of 10 (Pt #1) medical records reviewed the Hospital failed to ensure the patient was provided medical information pertaining to a wound, at discharge. This has the potential to affect all patients receiving care in the Behavioral Health Unit with an average daily census of 12.

Findings include:

1. The medical record of Pt #1 was reviewed on 9/28/2021- 9/29/2021. Pt #1 was admitted to the Behavioral Health Unit on 9/4/2021 with a diagnosis of acute psychosis-danger to self and family. The initial admitting documentation on 9/4/2021 at 2:54 AM indicated a small healing wound on left heel. On 9/4/21 at 2:54 AM, Pt #1 was given a Braden (skin assessment) score of 21 (score of 19 or greater is at risk for skin issues). The record lacked any documentation of wound care or wound interventions at the time of discharge.

2. On 9/29/2021 at approximately 2:00 PM, an interview was conducted with the Behavioral Health Director (E #1).
E #1 reviewed Pt #1's medical record and agreed a Plan of Care was not initiated for the wound.

3. On 9/29/2021 at approximately 2:30 PM an interview was conducted with the Registered Nurse (E #4) responsible for discharging Pt #1 on 9/16/2021. E #4 reviewed Pt #1's medical record and agreed a wound assessment was not completed on the day of discharge. Pt #1 stated "I was not aware there was a wound. At that time (9/16/2021) we were not required to do a head to toe assessment daily on discharge."


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