HospitalInspections.org

Based on document review, observation, and interview nursing services failed to review medications with patient at discharge for 1 of 1 patient observed (P11), and failed to ensure that patient received a daily shower in 1 of 10 MR reviewed (P1).


Findings include:

1. Review of policy/procedure "Medication Reconciliation (Admission and Discharge Medications)" PolicyStatID: 12197197, last approved 08/2022, indicates under Medication Reconciliation Procedure:
D. Discharge Reconciliation: At the time of discharge the Medical Doctor or Registered Nurse will review the discharge medications with the Medication Reconciliation List that was completed at the time of admission.
3. The Medication Reconciliation List will be reviewed with the patient and/or significant other at the time of discharge. During this education process, the nurse will review any changes to previous home medication dose or schedule, when the next dose is due, and all new medications that will be added to the patient's home medication regimen. Food and Drug interaction will also be discussed with the patient.
5. Provide the patient (or family as needed) with written information on the medication the patient should be taking when he or she is discharged from the hospital or at the end of an outpatient encounter. This will include name, dose, route, frequency, and purpose.

2. Review of policy/procedure titled, "Patient Personal Care," PolicyStatID: 12197137, last approved 08/2022, indicates under Policy:
All patients admitted to the hospital will be supported and educated in activities of daily living (ADLs), focusing on personal hygiene and grooming.
Under Procedure: Definition:
CMS defines ADLs as activities related to personal care, which includes the following:
Bathing/showering
Under Education:
All patients will be provided education upon admission regarding the process for ADLs, including but not limited to:
Bathing/showers will be offered daily
Under General Care:
All patients shall be encouraged or assisted in grooming daily or more often as needed.

3. Review of P1 MR lacked documentation of completed shower on 10/21/24. MR lacked documentation of refusal to shower on 10/21/24.

4. On 01/07/25 at approximately 2:30 p.m. this surveyor, accompanied by A1 (Project Chief Executive Officer, Interim Director), was escorted to the unit to observe the nurse, A5 (Director of Nursing [DON]), conduct the discharge of a current patient (P11). During this observation A5 failed to review the patient's discharge medications with the patient.

5. In interview with A8 (BHA) on 01/08/25 at approximately 1:10 p.m., indicated patients are asked every day in the a.m. and p.m. if they want to take a shower. A8 indicated the patient has the right to refuse. If the patient does refuse, A8 encourages the patient to wash up at the sink. Showering is documented on the 15-minute check sheet. If the patient refuses, A8 informs the nurse and documents it on the 15-minute check sheet.