HospitalInspections.org

Based on policy review, medical record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care needs for patients and ensure identified care needs were met for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's policy, "Plan for the Provision of Care," revealed, "...STRUCTURE...A RN [Registered Nurse] is responsible for identifying each patient's nursing care needs and providing or directing care of each patient in accordance with state law ...STANDARDS OF CARE...Each patient can expect to have their needs assessed and their plan of care implemented based on the information gathered. Their needs are assessed initially by an RN and continuously monitored and adapted by qualified personnel during the stay...Legal Responsibilities of Licensed Nurses...The RN will delegate and supervise nursing responsibilities to the licensed practical nurse and to the patient care technician [PCT]...NCP [Nursing Care Partner (or PCT)/Nurse Extern/Paramedic: Serves as team member who...Provision of basic physical needs as delegated, including but not limited to: personal care, bed making/changing, turning, ambulating, and promoting a safe environment..."

2. Medical record review for Patient #1 revealed an admission date of 9/5/20 with diagnoses which included Acute Cerebrovascular Accident, Hypertensive Emergency, Aortic Thrombosis, History of Clotting Disorder, History of Seizure Disorder, Carotid Artery Aneurysm, and Obesity.

A Progress Note dated 9/13/20 revealed Patient #1 was assessed as awake, alert, oriented to person but not to year or city. Patient #1 was assessed with mild expressive aphasia, right inattention, and right-sided weakness (weaker in right upper extremity than right lower extremity).

Review of the Activities of Daily Living and Nutrition Flowsheet from 9/10/20 through 10/1/20 revealed there was no documentation Patient #1 received a bath on 9/13/20, 9/15/20-9/18/20, 9/23/20, 9/25/20-9/26/20 or 9/28/20-9/30/20. There was no documentation Patient #1 refused a bath on any of the dates listed.

3. In an interview in the Board Room on 10/1/20 at 10:38 AM, the Clinical Manager for the Neurologic Medical Unit stated each patient should be bathed every day. The Clinical Manager stated if a patient did not receive a bath on the first shift, the PCT should communicate it during the bedside shift report to the oncoming PCT so the patient could be bathed on the next shift. The Clinical Manager stated if a patient refused a bath, staff should document the refusal in the medical record.

In an interview in the Board Room on 10/1/20 at 2:00 PM, the Quality Manager confirmed the baths or the refusal of baths were not consistently documented for Patient #1.