HospitalInspections.org

Based on document review and interview, the Registered Nurse failed to follow the P&P (Policy & Procedure) related to Patient Personal Care for bathing offered daily; in the patients MR (Medical Record), for 3 of 10 MR's reviewed. (Patients # 5, # 6, & # 8).

Findings include:

1. Review of hospital policy titled: "Patient Personal Care", Policy Stat ID 12197137; indicated Bathing/showers will be offered daily; All patients shall be encouraged or assisted in grooming daily or more often as needed. Last revised 1/2020.

2. Review of Patient # 5 MR, indicated the following:
A. Patient admitted to APH # 40 (Acute Psychiatric Hospital) on 2/29/2024.
B. MR lacked documentation in daily flowsheets and/or daily notes for ADL's (activities of daily living) - hygiene care/bathing, offered or completed or refused, for the following days: 3/1/2024, 3/2/2024 and 3/3/2024.

3. Review of Patient # 6 MR, indicated the following:
A. Patient admitted to APH # 40 on 9/15/2023.
B. MR lacked documentation in daily flowsheets and/or daily notes for hygiene care/bathing, offered or completed or refused, for the following days/timeframes: September 2023: 9/16/2023 - 9/20/2023; 9/24/2023 - 9/28/2023; October 2023: 10/4/2023 - 10/14/2023; 10/18/2023 - 10/20/2023; 10/25/2023 - 10/28/2023
November 2023: 11/4/2023 - 11/13/2023; 11/23/2023 - 11/27/2023
December 2023: 12/7/2023 - 12/12/2023; 12/23/2023 - 12/31/2023
January 2024: 1/12/2024 - 1/14/2024; 1/21/2024 - 1/31/2024
February 2024: 2/1/2024 - 2/6/2024; 2/8/2024 - 2/11/2024; 2/16/2024 - 2/20/2024

4. Review of Patient # 8 MR, indicated the following:
A. Patient admitted to APH # 40 on 2/4/2024.
B. MR lacked documentation in daily flowsheets and/or daily notes for hygiene care/bathing, offered or completed or refused, for the following days: 2/8/2024, 2/11/2024 and 2/12/2024.

5. In interview on 3/5/2024 at approximately 10:40 am, and at approximately 4:25 pm, with A # 3 (Quality/Risk), confirmed/verified the following:
A. That hygiene documentation is to be charted on flowsheet in MR; for daily completed, or chart if patient refused.
B. That the above noted MRs lacked hygiene documentation.

6. In interview on 3/5/2024 at approximately 12:45 pm, while on tour; with N # 1 (RN {Registered Nurse} - Staff Nurse), confirmed BHAs (Behavioral Health Associate) responsibility to document hygiene; nurse reviews for completeness of documentation on flowsheet.