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SAINT THOMAS MIDTOWN HOSPITAL
FORM AND RETENTION OF RECORDS
Tag No.: A0438
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 1/1/19 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 3/4/19 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 3/11/19 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.