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INDIANA UNIVERSITY HEALTH
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, facility nursing staff failed to complete and/or document daily CHG (Chlorhexidine Gluconate) bathing for 3 of 10 medical records reviewed (P1, P2, and P9); and failed to replace external urinary catheters for 2 of 10 medical records reviewed. (P1 and P9)
Findings Include:
1. The facility policy titled, "Chlorhexidine Gluconate Bathing", no policy number, publication date 12/01/2022, indicated under: V. POLICY STATEMENTS. B. A daily chlorhexidine gluconate bathing treatment will be given to all adult patients in participating units unless contraindicated.
2. Manufacturer instructions for use titled, "Sage PrimaFit External Urine Management for the Female Anatomy", no policy number, publication year 2023, indicated under: Placement. Step 12. Replace device every 12-24 hours, or if soiled with stool or bodily fluids other than urine. Dispose of device per hospital protocol and local regulations.
3. MR for P1 was reviewed and indicated P1's MR lacked documentation of required CHG bathing for dates 6/7/24, 6/8/24, 6/9/24, and lacked documentation that his/her external urinary catheter was changed every 12-24 hours per the manufacturer's instructions for use on days 6/8/24-6/9/24.
4. MR for P2 was reviewed and indicated P2's MR lacked documentation of required CHG daily bathing for dates 6/26/24, 6/28/24, 6/29/24, and 6/30/24.
5. MR for P9 was reviewed and indicated P9's MR lacked documentation of required CHG bathing for dates 6/1/24, 6/4/24, 6/23/24, 6/24/24, and lacked documentation that his/her external urinary catheter was changed every 12-24 (twenty-four) hours per the manufacturer's instructions for dates 6/5/24, 6/6/24, 6/19/24, 6/20/24, 6/23/24, 6/24/24, 6/25/24, and 6/26/24.
6. In an interview on 7/2/24 at approximately 3:40 pm with A3 (Clinical Nurse Specialist) confirmed daily chlorhexidine bathing treatments were not completed daily for patients P1, P2, and P9 in participating unit and external urinary catheter replacements were not completed every 12-24 hours per facility policy and/or manufacturer's instructions for use indicated but should have been for P1 and P9.