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LAKE CUMBERLAND REGIONAL HOSPITAL 305 LANGDON STREET SOMERSET, KY 42503 May 2, 2017
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview, record review, and review of the facility's policy, it was determined the facility failed to evaluate nursing care for one (1) of ten (10) patients (Patient #1) in accordance with the facility's policy. Patient #1's intake and output record revealed the patient did not have a bowel movement from 02/27/17 to 03/06/17 (seven days); however, there was no evidence the clinical information was reported to the patient's physician as required by the facility's policy. In addition, the facility failed to ensure Patient #1 received a bath from 02/27/17 to 03/05/17 (six days).

The findings include:

1. Review of facility's policy titled "Notification of Physician of Change in Patient Condition," approved 10/03/14, revealed it was the responsibility of the nurse to communicate new clinical information to the responsible physician. Changes in the patient condition that should be communicated included but were not limited to changes/alterations in output that may indicate fluid balance excess or deficit.

Medical record review revealed the facility admitted Patient #1 to the Transitional Care Unit (TCU) on 02/27/17 with diagnoses that included Morbid Obesity, Diabetic Neuropathy, Hypertension, Hiatal Hernia, GERD, Urinary Incontinence, Constipation, and Back Pain resulting in a fall and ambulatory dysfunction.

A review of the provider notes revealed Patient #1 received Morphine SR 15 mg and Norco 10/325 mg (narcotic pain medications that can cause constipation) for complaints of ongoing back pain. Review of Patient #1's intake and output record revealed Patient #1 did not have a bowel movement from 02/27/17 through 03/06/17 (seven days).

Interview on 05/02/17 at 4:00 PM with Registered Nurse (RN) #1, who provided care for Patient #1, revealed Milk of Magnesia (a laxative medication) was administered for Patient #1's complaints of constipation on 03/01/17 and 03/05/17, but the medication was not effective and the resident did not have a bowel movement. However, there was no evidence that Patient #1's physician was notified of the patient's condition. RN #1 stated, "I guess we should have" notified the physician.

Interview with the Nurse Manager on 05/01/17 at 5:00 PM revealed staff normally documented on the daily intake and output computerized log when a patient had a bowel movement. The Nurse Manager reviewed Patient #1's medical record and was unable to find documentation that the patient had a bowel movement from 02/27/17 to 03/06/17 (seven days). The Nurse Manager also confirmed that Milk of Magnesia was administered on 03/01/17 and again on 03/05/17 for Patient #1's complaints of constipation, but was not effective. The Nurse Manager gave no explanation why the responsible physician was not notified of Patient #1's change in condition.

2. A review of the facility's "Bathing a Patient" policy, approved 04/13/16, revealed the policy did not address how often a bath should be provided. The policy stated staff should document that a bath was provided on the "ADL [Activities of Daily Living] documentation screen," noting the level of assistance required, skin condition, and any significant findings.

An interview with Patient #1's family on 05/01/17 at 4:50 PM revealed Patient #1 did not receive a bath at the facility and the patient "stunk" when he/she was discharged .

Interview with Certified Nurse Aide (CNA) #1 on 05/02/17 at 3:30 PM and with the Nurse Manager on 05/01/17 at 5:00 PM revealed there was no documentation that Patient #1 received a bath from 02/27/17 to 03/05/17. Further interview with CNA #1 revealed she provided care for Patient #1 but did not recall giving the patient a bath. CNA #1 stated staff always offered to assist patients with bathing daily, but did not always document if a patient refused a bath. However, CNA #1 gave no explanation why Patient #1 did not receive a bath for six (6) days.

Further interview with the Nurse Manager on 05/01/17 at 5:00 PM revealed patients received daily baths and, if a patient refused, it was documented in the medical record. The Nurse Manager reviewed Patient #1's medical record and found documentation which showed Patient #1 received a bath on 03/05/17; however, there was no documentation to show Patient #1 had a bath from 02/27/17 to 03/05/17, or that the patient refused a bath.