HospitalInspections.org

Based on document review and interview, the Registered Nurse failed to follow the P&P (Policy & Procedure) related to Patient Personal Care for bathing offered daily for 4 of 10 Medical Records (MR's) reviewed. (Patients # 7, # 8, # 9 & # 10).

Findings include:

1. Review of established hospital policy titled: "Patient Personal Care", indicated on page 1, under Education, 2nd point; "Bathing/showers will be offered daily", and under General Care, 1st point; "All patients shall be encouraged or assisted in grooming daily or more often as needed". Last revised 1/2020.

2. Review of Patient # 8 MR, indicated the following:
A. Patient admitted to APH # 40 (Acute Psychiatric Hospital) on 12/29/2023.
B. Patient discharged/transferred to AH # 60 (Acute Care Hospital) on 1/18/2024.
C. MR lacked documentation in daily flowsheets and/or daily notes for ADL's (activities of daily living) - hygiene care/bathing, offered or completed or refused, for the following days: 12/30/2023, 12/31/2023, 1/2/2024, 1/3/2024, 1/4/2024, 1/6/2024, 1/9/2024, 1/12/2024, 1/13/2024 and 1/16/2024.

3. Review of Patient # 7 MR, indicated the following:
A. Patient admitted to APH # 40 on 10/28/2023.
B. Patient discharged on 12/7//2023.
C. MR lacked documentation in daily flowsheets and/or daily notes for hygiene care/bathing, offered or completed or refused, for the following days: 10/29/2023, 10/30/2023, 10/31/2023, 11/1/2023, 11/3/2023, 11/4/2023, 11/6/2023, 11/10/2023, 11/13/2023, 11/15/2023, 11/17/2023, 11/18/2023, 11/19/2023, 11/20/2023, 11/21/2023, 11/24/2023, 11/27/2023, 11/28/2023, 11/30/2023, 12/1/2023, 12/2/2023, 12/4/2023, 12/5/2023 and 12/6/2023.

4. Review of Patient # 9 MR, indicated the following:
A. Patient admitted to APH # 40 on 12/14/2023.
B. Patient discharged on 12/22/2023.
C. MR lacked documentation in daily flowsheets and/or daily notes for hygiene care/bathing, offered or completed or refused, for the following days: 12/15/2023, 12/17/2023, 12/19/2023 and 12/21/2023.

5. Review of Patient # 10 MR, indicated the following:
A. Patient admitted to APH # 40 on 12/19/2023.
B. Patient discharged on 12/26/2023.
C. MR lacked documentation in daily flowsheets and/or daily notes for hygiene care/bathing, offered or completed or refused, for the following days: 12/21/2023, 12/22/2023, 12/24/2023 and 12/25/2023.

6. In interview on 1/29/2024 at approximately 2:50 pm, with A # 2 (LPN {Licensed Practical Nurse} - Nursing), confirmed that staff should be documenting hygiene completed or hygiene refusals on flowsheets.

7. In interview on 1/30/2024 at approximately at approximately 10:43 am, with NS # 25 (Behavioral Health Associate - staff), confirmed that Aides/staff responsible for documenting for bathing, hygiene.

8. In interview on 1/30/2024 at approximately 10:00 am, with A # 3 (Director Quality Control), confirmed that the MR lacking some entries for daily hygiene.