The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NORTH BALDWIN INFIRMARY 1815 HAND AVENUE BAY MINETTE, AL 36507 April 12, 2017
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, review of policy and procedures and interviews, the hospital failed to provide and/or document the provision of showers and/or baths to Patient Identifier (PI) # 1 and PI # 7, two patients assessed as requiring assistance with hygiene. This affected two of nine sampled patients' medical records who were reviewed for the provision of hygiene services by staff and has the potential to affect all patients with a diagnosis of an alteration in mental status and require the assistance of staff for personal hygiene.


Findings include:


I. Medical Record Review:

1. PI # 1 was admitted on [DATE] with diagnoses to include Altered Mental Status with disturbance of behavior and vague psychosis.

A review of the Initial Nursing assessment dated [DATE] revealed PI # 1 requires assistance with bathing.

A review of the medical record revealed PI # 1 was showered, shaved and his/her hair was washed on 3/13/17, six days after admission. The next documentation of care (shower, shave, hair washed) was on 3/15/17 (day of discharge).

Although PI # 1 was hospitalized for eight days, there are only two documented occurrences of showers given by staff.

2. PI # 7 was admitted on [DATE] with diagnoses to include Altered Mental Status and Vague Auditory Perceptual Disturbance.

A review of the medical record on 4/12/17 revealed no documentation to indicate PI # 7 had been assisted with a shower and/or bath for nine days (since PI # 7's admission on 4/3/17). This was verified by the Risk Manager, Employee Identifier (EI) # 1 on 4/12/17 at 2:25 PM.


II. Policy and Procedures:

1. SBH ADL's (Senior Behavioral Health- Activities of Daily Living). Provided and documented by the SBH Program Director, EI # 2, on 4/11/17 at 11:55 AM.

"...Baths are at least every other day and most are daily. There is a shower schedule (see attached) and this information should be noted on VS (Vital Signs) sheet...entered into EPIC (electronic medical record system)..."


III. Interviews:

During an interview on 4/12/17 the Program Director, EI # 2 stated patients should be, "Showered at least every other day."

The American Association of Clinical Nursing continues to advocate for daily bathing to improve hygiene and promote patient comfort. (www.Nurse.com).