HospitalInspections.org

Based on document review and interview, the facility staff failed to provide a safe setting by failure to ensure patient care was ordered by a physician and failure to document all findings in the nursing assessment for one (1) of five (5) patients (Patient #1).

The findings include:

On 12/12/18, the medical record of Patient #1 was reviewed and the following was noted:
Patient #1 diagnoses were Chronic Respiratory Failure, Anoxic Encephalopathy, Dysphagia, Gastrointestinal Dysmotility and Yeast Dermatitis.

The following head to toe nursing assessments were reviewed and lacked documentation of Patient #1's pubic area being shaved:
6/19/18 at 11:54 A.M. and 11:49 P.M.;
6/20/18 at 4:35 P.M.;
6/21/18 at 3:11 A.M. and 3:25 P.M.;
6/22/18 at 12:59 A.M., 2:04 P.M. and 8:16 P.M.;
6/23/18 at 1:40 P.M.;
6/24/18 at 4:31 A.M., 10:54 A.M. and 7:54 P.M.;
6/25/18 at 1:01 P.M. and 10:27 P.M.

There was no physician's order to shave Patient #1's pubic hair. There was documentation the family or physician had been notified of the incident.

The Physician Orders on 6/6/18 included orders for Nystatin Powder to folds tid (three times a day) for 7 (seven) days and Diflucan 200 mg (milligrams) Peg (feeding tube) daily times 7 (seven) days. The Physician's diagnosis on 6/6/18 was Yeast dermatitis.
The Physician's notes dictated on 6/23/18 documented: "Apparently, the family are upset that she was shaved in her pubic area without any notification. Nursing and Administration are looking into it."

Staff Member #5 stated: "During the nurse's shift head to toe assessment on 6/22/18, it was discovered Patient #1's pubic area had been shaved. The nurse notified the husband and the physician."