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Based on nursing leadership interview, medical record review and staff interviews the hospital staff failed to have evidence of a daily bath offered for 4 of 5 patients records reviewed. (Patient #6, 7, 2 and #10).

Request on 3/14/2024 for the hospital policy for bathing or hygiene revealed there was not one available for review.

Interview with the Nursing Leadership team (RN #5, QD #10) revealed it was the expectation for nursing staff to offer a patient a daily bath.

1. Open medical record review on 03/15/2024 revealed Patient #6, a 75-year-old male
who presented on 03/10/2024 at 2223 to the hospital Emergency Department after a fall at home.
Review revealed Patient #6 was transported by ambulance to the hospital for evaluation which revealed a left humerus fracture resulting in a non-surgical treatment plan. Review revealed an Occupational Therapy (OT) Evaluation and Treatment Note on 03/12/2024 at 1243 by OT #6 which had evidence of Patient #6 needing moderate supervision with hygiene/bathing assistance. Record review failed to reveal documentation of a bath offered or declined (03/11/2024 through 03/15/2024) for 5-days reviewed.

Interview on 03/15/2024 at 0857 with the Senior Nursing Officer, RN #5 revealed the expectation of the facility was that all patients would be offered a daily bath, and the offer or refusal would be documented in the medical record. Interview revealed the hospital's expectation for a daily bath was not met for Patient #6.

2. Open medical record review on 03/15/2024 revealed Patient #7, a 63-year-old male who presented on 03/08/2024 at 0707 for a scheduled colon surgery. Review of Physical Therapy (PT) Progress Notes revealed on 03/09/2024 at 1408 Patient #7 declined evaluation secondary to increased pain. Record review failed to reveal documentation of a bath offer or decline (03/12/2024 through 03/14/2024) for 3 of 7 days reviewed. Record review revealed on 03/14/2024 at 1516 Physical Therapy (PT) Progress Notes by PT #7 revealed "...Impairments are limiting Pt. from completing ADL's (Activity of Daily Living, i.e., bathing, toileting etc.)..." Record review failed to reveal Patient #7 was offered a bath for 3 of 7 days.

Interview on 03/15/2024 at 0857 with the Senior Nursing Officer, RN #5 revealed the expectation of the facility was that all patients would be offered a daily bath, and the offer or refusal would be documented in the medical record. Interview revealed the hospital's expectation for a daily bath was not met for Patient #7.

3. Closed medical record review on 03/13/2024 revealed Patient #2, a 90-year-old female who presented on 05/16/2022 at 2047 to the hospital Emergency Department (ED) after a fall at home. Review revealed Patient #2 was transported by ambulance to the hospital for evaluation which revealed the need on 05/17/2022 for surgical repair of a fractured right hip. Review of the History and Physical completed by the Medical Provider (NP) #1 on 05/17/2022 at 1159 revealed a plan to admit for hip fracture and possible pubic fracture "...Patient is at moderate risk for surgery given her chronic hypoxic respiratory failure/COPD, Age/Fragility and CAD (Coronary Artery Disease) ..." Record review revealed Patient #2 had a 20-day admission length of stay, whereby a sampled 7-day period (05/25/2022 through 05/31/2022, while in Intensive Care Unit and Medical Surgical Telemetry Unit) failed to reveal evidence of a bath on 5/27/2022 through 5/30/2022, 4 of 7 days for Patient #2.

Interview on 03/15/2024 at 0857 with the Senior Nursing Officer, RN #5 revealed the expectation of the facility was that all patients would be offered a daily bath, and the offer or refusal would be documented in the medical record. Interview revealed the hospital's expectation for a daily bath was not met for Patient #2.






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4. Closed medical record review on 03/14/2024 revealed Patient #10, a 70-year-old female patient who presented to the emergency department on 03/09/2024 at 1449 with complaints of left leg heaviness, and left arm tingling. Patient #10 was diagnosed with an acute CVA (cerebrovascular accident) and was admitted to the floor on 03/09/2024 at 1906. Review of the Occupational Therapy (OT) Note dated 03/11/2024 by OT #9 revealed "...moderate assist with bathing..." Review of the Nursing Flowsheet failed to reveal evidence of an offer or declined offer for a daily bath on 03/09/2024 through 03/12/2024 (3 days) for Patient #10. Patient #10 was discharged home with home health and physical therapy on 03/12/2024 at 1110 with family.

Interview on 03/15/2024 at 0857 with the Senior Nursing Officer, RN #5 revealed the expectation of the facility was that all patients would be offered a daily bath, and the offer or refusal would be documented in the medical record. Interview revealed the hospital's expectation for a daily bath was not met for Patient #10.

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