HospitalInspections.org

Based on document review and interview, nursing services failed to ensure call lights were answered in a timely manner in 2 of 3 patient rooms reviewed (rooms 4225 and 4226); failed to document patient repositioning every 2 hours for 1 of 10 patient medical records (MRs) reviewed (P6); failed to document every four-hour entries for patient vital signs for 1 of 10 patient MRs reviewed (P6); and failed to document daily patient personal hygiene for 1 of 10 patient MRs reviewed (P6).


Findings include:
1. The facility policy/procedure titled, "Skin Care Policy: Pressure Injury Prevention and Wound Management," PolicyStat ID: 13405907, last approved 12/2023; indicated under Pressure Injury Prevention/Interventions: 2. Interventions include but are not limited to: j. When in bed: iii. Reposition or if patient able, encourage/educate patient to reposition every 2 hours as appropriate and safe for medical condition. (minimum every two-hour turns).

2. The facility policy/procedure titled, "Patient Personal Hygiene: Guidelines For Providing Care (CHG Bathing)," PolicyStat ID: 15745546, last approved 07/2024; indicated under Policy Statement: Personal Hygiene (including washing hair) is to be offered to all in-patients at least daily and documented as completed or refused in the patient's medical record.

3. Review of Nurse Call Detail Report for dates from 03/09/25 - 03/10/25 indicated patient call lights were not answered timely 20 times the call light was activated out of 91 call light activations. The report indicated the following:
a. Room 4225 call light report indicated the call light was not answered timely 14 out of 66 times the call light was activated. These include but are not limited to 03/09/25 - 7 minutes 29 seconds, 20 minutes 55 seconds, 17 minutes 27 seconds, 18 minutes 32 seconds, 11 minutes 48 seconds, 51 minutes 14 seconds, and 10 minutes 42 seconds. On 03/10/25 - 28 minutes 43 seconds, 36 minutes 45 seconds, 10 minutes 13 seconds, 44 minutes 07 seconds, 7 minutes 48 seconds, and 14 minutes 12 seconds.
b. Room 4226, P6's room, call light report indicated the call light was not answered timely 7 out of 43 times the call light was activated. These include but are not limited to 03/09/25 - 26 minutes 44 seconds, 7 minutes 21 seconds, and minutes 14 seconds. On 03/10/25 - 7 minutes 51 seconds, 33 minutes 16 seconds, 43 minutes 16 seconds, and 59 minutes 47 seconds.

4. Review of MR for P6 indicated the following:
a. Patient Care Flow sheet lacked every two-hour entries for turns on the following dates: 03/03/25, 03/04/25, 03/05/25, 03/06/25, 03/07/25, 03/08/25, 03/09/25, 03/10/25, 03/11/25, 03/12/25, 03/13/25, 03/14/25, and 03/15/25.
b. P6 lacked daily documentation of receiving personal hygiene on the following dates: 03/03/25, 03/04/25, 03/05/25, 03/06/25, 03/07/25, 03/08/25, and 03/11/25.
c. Physician order on 03/02/25 indicated vital signs assessed every four hours.
d. Vital Signs - Adult sheet, lacked every four-hour entries for vital signs on the following dates:
03/03/25, 03/04/25, 03/05/25, 03/06/25, 03/07/25, 03/08/25, 03/09/25, 03/10/25, 03/12/25, 03/13/25, 03/14/25, and 03/15/25.

5. On 04/02/25 at approximately 4:55 p.m., an interview with A4 (RN) confirmed patients get a chlorhexidine bath daily. The unit has a monitor technician, they will answer call lights and notify the nurse or Patient Care Technician (PCT), it depends on the need of the patient.

6. On 04/03/2025 at approximately 10:05 a.m., an interview with A6 (Nursing Manager) and A7 (Nursing Director), confirmed the nurses on their units follow the physician order for patient assessment including vital signs.