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Based on interviews and record reviews, the facility failed to ensure nursing services were provided to meet the ongoing needs of patients in 1 out of 10 records reviewed (Patient #2).

The failure resulted in the patient's physical needs not being addressed.

Findings

Policy

According to the policy Assignment of Nursing Care, available nursing resources are allocated in a manner which provides for each individual patient's care needs in a safe, cost effective and compassionate manner. Additionally, the assignment of patient care shall be consistent with patient needs as determined by the nursing process. The RN (Registered Nurse) makes patient care assignments, supervises and evaluates the nursing care of each patient.

According to Documentation Guidelines for Entries in and Maintenance of the Medical Record, documentation must be recorded by the individual providing the care to the patient.

1. The facility failed to ensure the hygiene needs of the patient were met.

a. Review of Patient #2's medical record revealed a female geriatric patient admitted to the orthopedic unit after surgery from 10/22/15 until 10/26/15. As a result of surgery Patient #2 experienced post-operative pain and a lowered ability to perform personal care without assistance.

Review of the Activity/ADL Assessment Forms (ADL Form), used by nursing staff to document all personal hygiene care completed, offered or refused by the patient, showed no shower, bath, gown or linen change was performed 10/22/15 through 10/24/15. For 3 days, there is no documentation to show Patient #2 had been offered and refused to bath, shower or have a gown and linen change.

b. On 07/18/16 at 9:11 a.m. Certified Nurse Aide (CNA #1) was interviewed. CNA #1 stated the duties of a CNA included assistance with baths and showers, linen changes, and ensuring the needs of the patient were met.CNA #1 further stated the care provided to patients was documented in the patient's Electronic Medical Record (EMR).

c. An interview was conducted with RN #9 on 07/18/16 at 9:54 a.m. RN #9 stated RNs and CNAs were responsible to assist patient's with daily personal hygiene care and provide complete care to those patients unable to assist in their own care. RN #9 stated after completing care of a patient, s/he would document the care in the nurse's narrative note section of the EMR and not the ADL From.

c. The Nurse Manager of a medical/surgical unit (Manager #2) was interviewed on 07/19/16 at 8:22 a.m. Manager #2 stated the expectation of the CNA was to offer a shower or bath to patients during their morning rounds. If the patient declines during morning rounds the CNA was expected to return later in their shift to make an additional offer of personal care.

d. In an interview with RN #8 on 07/19/16 at 9:39 a.m., she stated all nursing staff were expected to document all care provided to patients within the patient's EMR. RN #8 also stated, in addition to nurse's narrative notes, there is an area within the EMR where the RN and CNA can document all personal care provided to the patient including bathing, linen changes and toileting. Additionally, RNB #8 confirmed the white communication board in each patient's room served only as a reminder of care to RNs and CNAs.

e. An interview was conducted with CNA #3 on 07/20/16 at 8:24 a.m. CNA #3 stated s/he was expected to perform morning rounds at the beginning of the shift to assess the personal care needs of each patient and provide assistance with meals, bathing, toileting and linen changes. CNA#3 stated, if a patient declines the offer of assistance with personal care s/he is required to notify the RN responsible for the care of the patient and the information is passed on to the next shift so that the offer of personal care can be made. Further, CNA #3 stated all care provided was documented in the patients EMR as required by facility policy.

f. On 07/20/16 at 9:09 a.m. an interview was conducted with the Nurse Manager (Manager #4) and the Director (Director #5) of the fourth floor care unit. Manager #4 stated the nursing staff documented each interaction with the patient on the communication board in the patient's room and was unsure which part of the ADL Form the CNA had access to within the EMR. Director #5 stated all nursing staff had access and received training for documentation on the ADL Form. Director #5 further stated all nursing staff was expected to document all hygiene care provided on the ADL From in the patient's EMR.

g. An interview was conducted with the Director of Clinical Informatics (Director #7) on 07/20/16 at 12:44 p.m. during review of the ADL Form. Director #7 stated s/he conducted training of all nursing staff on the use of the EMR and all nursing staff had access to the ADL Form for documentation proposes. Director #7 stated there had been issues in ensuring the CNAs documented the care provided on the ADL Form.

h. The Director of the orthopedic unit (Director #6) was interviewed on 07/20/16 at 10:58 a.m. Director #6 stated personal care was expected to be provided daily and should have been documented on the ADL From within the patient's EMR. Additionally, Director #6 stated CNAs struggle with the documentation on the ADL Form.

The facility did not maintain an effective means to ensure patient's received personal needed and lacked a consistent manner of tracking when or if this care was provided resulting missed personal hygiene for Patient #2.