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.

SAINT THOMAS MIDTOWN HOSPITAL 2000 CHURCH ST NASHVILLE, TN 37236 March 25, 2019
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, medical record review, and interview, the facility failed to maintain a complete and accurate medical record for personal care for 3 patients (#2, #8, and #9) of 9 patients reviewed.

The findings included:

Review of facility policy "...Computerized Documentation..." dated 1/2012, revealed "...Any patient care provided during the shift needs to be documented..."

Medical record review revealed Patient #2 was admitted to the facility on [DATE] with diagnoses including Abnormal Chest Computed Tomography (CT) Scan with Fluid Collection in the Mediastinum (between the lungs), Anemia, Chronic Obstructive Pulmonary Disease, Hypertension, and Pulmonary Embolism (blood clot). Continued review revealed no documentation Patient #2 received or refused a bath on 1/16/19 - 1/23/19, 1/27/19 - 1/29/19, and 2/2/19 - 2/3/19 (13 days).

Medical record review revealed Patient #8 was admitted to the facility on [DATE] with diagnosis of Chronic Diastolic Heart Failure. Further review revealed no documentation Patient #8 received or refused a bath on 3/16/19 and 3/17/19 (2 days).

Medical record review revealed Patient #9 was admitted to the facility on [DATE] with diagnosis of Dyspnea (shortness of breath). Further review revealed no documentation Patient #9 received or refused a bath on 3/16/19 and 3/17/19 (2 days).

Interview with the 5th Floor Nurse Manager on 3/20/19 at 1:00 PM, in the Administrative Conference Room, revealed all patients should be offered a bath every day and the completion of the bath or the refusal of the bath should be documented in the patient's electronic medical record. Further interview confirmed Patient #2's medical record did not contain documentation regarding bathing on 1/16/19 - 1/23/19, 1/27/19 - 1/29/19, and 2/2/19 - 2/3/19. Continued interview confirmed Patient #8's medical record did not contain documentation regarding bathing on 3/16/19 - 3/17/19. Further interview confirmed Patient #9's medical record did not contain documentation regarding bathing on 3/16/19 - 3/17/19.