HospitalInspections.org

Based on record review, observation, and interview the facility failed to ensure that all licensed nurses are following policies and procedures. This deficient practice is likely to lead to staff not providing quality patient care.

The findings are:

A. Record review of facility's policy titled "L.12.07 Skin Care Protocol" stated if a patient is identified "at risk" for skin breakdown the following intervention should be implemented "ii. Bathe daily with mild soap, rinse and dry thoroughly."

B. Record review of P (Patient) 5's medical record under demographics revealed P5 was admitted to the facility on 04/05/2024. According to the document titled "Patient Risk Profile" revealed P5 was a high risk for skin breakdown.

C. Record review of the facility's document titled "Bath Schedule" revealed P5 was offered baths weekly, not daily.

D. During an interview on 09/23/24 at 11:23 AM with P5, when asked how often he was offered a bath P5 stated "Once a week."

E. During an interview with S (staff) 6, Clinical Staff Member, when asked how often patients should be bathed S6 stated "it should be daily, the night shift does the odds [odd room numbers] and day shift does the evens [even room numbers]".

F. Record review of the facility's policy titled "E.5.08 Turn Teams and Hourly Purposeful Rounding" stated "Each shift the Charge Nurse will Identify 3 Members of the turn team and schedule the rounding for every two hours on either even or odd hours to reposition patients who are unable to reposition themselves".

G. During an observation on 09/23/24 at 10:24 AM of the board behind the nursing station revealed turn team assignments were not assigned.

H. During an interview on 09/23/24 at 10:24 AM with S2, clinical staff member, when asked who is on the turn teams, S2 explained she usually writes turn teams on the board but she forgot to "make assignments today."