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Based on record review, interview, and policy review, the facility failed to ensure licensed staff adhered to hospital policy for 1 (Patient 4) of 3 patients reviewed for bathing and 1 (Patient 6) of 3 patients reviewed for hair washing. Failure to adhere to hospital policy has the potential to place patients at risk for unmet care needs.

Findings Include:

Review of a facility policy titled, "Guidelines and Protocols, Clinical," revised 10/01/23, indicated, "To ensure quality patient care, certain standards of care must be upheld. The following table outlines basic tasks and designates the minimum frequency with which these tasks must be performed to maintain quality care." A table included in the policy revealed, "Hair shampooed Weekly" and "Patient bathed/hair combed/shaved Daily."

Patient 4

Review of Patient 4's demographic record revealed the facility admitted Patient 4 on 05/17/24 with admitting diagnoses of shortness of breath and acute respiratory failure with hypoxia. According to the patient demographic record, the facility discharged Patient 4 on 06/11/24.

Patient 4's skin care and urinary catheter care flowsheet dated 06/07/24, revealed no documented evidence that bathing was performed.

Patient 4's skin care and urinary catheter care flowsheet dated 06/08/24, revealed no documented evidence that bathing was performed.

During an interview on 11/14/24 at 10:23 AM, Certified Nursing Assistant (CNA) 12 stated that the facility divided the baths between day and night shift. CNA 12 said patients in even numbered rooms received baths at night, and patients in odd numbered rooms received baths during the day. CNA 12 stated, however, if a patient was malodorous or soiled, they would be bathed regardless of the time of day. According to CNA 12, during a day bath, she used one of the shampoo caps, and primarily used the bath wipes that were kept in the warmer, but if needed, the facility had the capability to do a traditional soap and water bath. CNA 12 said if a patient refused hygiene care that would be documented, and she would document that the care was offered.

During an interview on 11/14/24 at 10:36 AM, Registered Nurse 2 stated bathing was expected to be completed daily, and perineal care was expected to be done every shift.

During an interview on 11/15/24 at 9:42 AM, the Director of Quality Management stated that she did not see staff documentation of a bath on 06/07/2024 or 06/08/2024 for Patient 4 and stated that the facility seemed to have missed a couple of baths.


Patient 6

Review of Patient 6's demographic record revealed the facility admitted Patient 6 on 05/31/24 with an admitting diagnosis of respiratory failure. According to the patient demographic record, the facility discharged Patient 6 on 07/13/24.

Review of Patient 6's "Comfort & Hygiene" flowsheet revealed documentation indicated the patient's hair was washed on 06/08/24 at 5:08 AM; 06/12/24 at 1:59 AM; 06/19/24 at 9:00 PM; 06/20/24 at 8:30 PM; 06/26/24 at 7:57 PM; 06/27/24 at 4:00 PM; and 06/29/24 at 10:47 PM. There was no documented evidence to indicate the patient's hair was washed from 06/29/24 through the date of their discharge on 07/13/24.

During an interview on 11/15/24 at 9:20 AM, the Director of Quality Management stated that hair washing could be with soap and water or with the shampoo cap. She stated that hair should be washed weekly.