HospitalInspections.org

Based on document review and interview, it was determined the facility failed to ensure that nursing staff performed and documented hygiene care for one (1) on nine (9) patients sampled.

The findings include:

In the morning of 05/21/24, the surveyor met with both Staff Member #1 and Staff Member #2 and was supplied the requested facility policy titled, "General Guidelines and Protocols for Nursing Staff" (Policy S05-G revised October 1, 2023)). The document delineated time-frame procedures for nursing-related care interventions, including hygiene care. The policy described that hygiene practices to include patient bathing should be performed at least daily and pericare should be performed every shift. .

On 05/22/24 at 9:30 am, the surveyor initiated the medical record review of Patients # (1-9) with the assistance of Staff Member #9 who served as navigator for the electronic medical record (EMR). The surveyor reviewed all "hygiene" care interventions within the "Comfort and Environment Interventions" flowsheet documentation throughout Patient #2's medical record. The surveyor confirmed with Staff Member #9 that there was no documentation of Staff Member #5 bathing or performing any other hygiene care interventions for the patient throughout the patient's hospitalization.

Additionally, the surveyor requested Staff Member #9 to search throughout other areas of the patient's chart to include the nursing progress notes for such documentation. Staff Member #9 confirmed there were no nursing notes or any other progress notes within Patient #2's hospitalization record that indicated that Staff Member #5 had performed any hygiene care interventions for the patient.

On 05/22/24 at 11:27 am, Staff Member #1 provided the surveyor with the "as-worked" staff assignment sheets, which indicated that Staff Member #5 was assigned as Patient #2's day nurse on 02/28/24, 03/30/24, 03/31/24, 04/20/24, 04/29/24.

On 05/23/24 at 1:33 pm, the surveyor conducted a phone interview with Staff Member #5. The employee advised they were assigned to care for Patient #2 on several occasions. The surveyor inquired with the employee regarding whether any hygiene-related patient care interventions were performed for the patient. Staff Member#5 stated they had bathed the patient in the presence of other staff following wound care but was unable to recall specific dates.

In the evening of 05/22/24, the surveyor confirmed with Staff Member #1 and Staff Member #2 that patient care interventions should be supported with documentation in the medical record.