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.


Based on policy review, medical record review, and interview, the hospital failed to develop and update a plan of care to address resistance to personal hygiene for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's policy, "Hospital Plan for Provision of Nursing Care," revealed, "...The delivery of nursing care at [Hospital #1] shall be understood as the purposeful and perpetual application of diversified talents with the common goal of positively impacting the health status of those entrusted to our care...Nurses engage in an infinite number of activities to provide quality patient care. Activities critical to the provision of patient care include, but are not limited to...Patient assessment and reassessment...Treatment plan preparation/revision...Assistance with activities of daily living ...Interdisciplinary collaboration and communication...Monitoring/facilitating satisfaction of basic needs..."

Review of the hospital's policy, "Reassessment," revealed, "...Reassessment is conducted by a Registered Nurse every 24 hours at a minimum. Additionally, reassessment occurs in the following circumstances...Change in the patient's condition...Patient injuries...R.N. [registered nurse] findings from the reassessment are documented in the patient's chart...As indicated by the patient's condition, length of stay, and level of care, the treatment team reassesses the patient in relation to progress toward treatment plan goal. These reassessments are documented on the Interdisciplinary Treatment Plan Update form..."

Review of the hospital's policy, "Personal Hygiene Assistance," revealed, "...The nursing staff of [Hospital #1] will assist patients as needed with personal hygiene, to include tub baths, showers, or bed baths to ensure patient cleanliness..."

2. Medical record review for Patient #1 revealed an admission date of [DATE] with diagnoses which included Schizoaffective Disorder Bipolar Type and Intellectual and Developmental Disability.

The "COMPREHENSIVE ASSESSMENT TOOL" dated 6/19/2021 revealed, "...General Appearance...Grooming...Neatly Groomed...Hygiene...Clean..."

The "STANDARIZED INTAKE TRIAGE FORM" dated 6/19/2021 revealed, "...Does patient require assist with ADLs [activities of daily living]?...No..."

The "HISTORY & [and] PHYSICAL EVALUATION" form dated 6/202/2021 revealed, "...General Appearance...Patient is a well-developed, well-nourished individual who does not appear to be acutely or chronically ill. Posture is appropriate. No observable disturbance of gait..."

Physician #1 documented in the Psychiatric Progress Note that Patient #1's general appearance was disheveled on 7/2/2021, 7/3/2021, 7/5/2021, and 7/7/2021. Physician #1 documented in the Psychiatric Progress Note that Patient #1's general appearance was disheveled and odorous on 7/4/2021.

Review of the Individual Treatment Plan initiated on 6/21/2021 revealed there was no documentation or revision of the plan to include Patient #1's refusal to shower, change clothes, or resistance to personal hygiene.

3. In an interview on 7/20/2021 at 1:00 PM, the Director of Quality stated she conducted interviews of staff after the hospital received a complaint filed from Patient #1's mother concerning her personal hygiene. The Director of Quality stated that from the interviews with staff, she discovered Patient #1 refused to bathe and refused to change clothes.

In an interview on 7/20/2021, the Director of Nursing stated she remembered Patient #1 looked disheveled. The Director of Nursing stated the technicians told her that they would ask Patient #1 to shower, and Patient #1 would step into the shower and get her hair wet but not wash.

In an interview on 7/20/2021 at 3:19 PM, Nurse #1 stated Patient #1 would stand under the water during a shower but not really wash. Nurse #1 stated it was reported to her [uncertain who reported] that Patient #1 was urinating on herself even though she was typically continent.

In an interview on 7/21/2021 at 8:09 AM, Nurse #2 stated Patient #1 was super-resistant to taking a shower and change her clothes. Nurse #2 stated Patient #1 would go into the shower, come out wet, and then put her old clothes back on.

In a phone interview on 7/21/2021 at 9:34 AM, Physician #1 stated Patient #1's self-care was insufficient. Physician #1 stated Patient #1's behavioral issues had improved, but there was no change in her intellectual issues.

In a phone interview on 7/29/2021 at 8:31 AM, Patient #1's mother stated when Patient #1 arrived home on 7/8/2021 her body odor was putrid.