HospitalInspections.org

Based on a review of patient records, facility documents, and interviews, the facility failed to ensure that nursing notes, reports of treatment, and other information needed to monitor the condition of patients were appropriately documented.

Findings were:
A review of the Facility Policy Titled "Nursing Process - CO-OM-07-49 - Last Approved Date: 04/23", addresses the facility's requirements for documentation in patients' medical records. See relevant excerpt below:
1."Nursing documentation reflects the elements of the nursing process. electronic documentation system allows for charting by exception with a focus on abnormal or significant findings ...
2.Documentation is completed in the electronic medical record. In cases in which electronic documentation is not available, the appropriate paper form(s) is/are used and is placed in the permanent medical record.
3. Scope of practice dictates the appropriateness and completion of documentation by RN's, LVN's and unlicensed personnel."

Review of the "Job Description" for the "Job Title: Registered Nurse" states in part:
"MAJOR JOB RESPONSIBILITIES
*Documents patient history, symptoms, medication, and care given."

Review of the "Job Description" for the "Job Title: Certified Nursing Assistant" states in part:
"MAJOR JOB RESPONSIBILITIES
"Completes pertinent documents...
"...Perform unit specific patient care tasks in accordance with skills checklist and documents on
the flowsheet"

A review of medical records for 2 of 2 patients (#1, #11) with orders to be turned every 2 hours (Q2h) revealed missing documentation from the mobility flowsheet for several dates during each patient's admission.

A review of patient #1's medical record revealed missing documentation from the Mobility Flowsheet for 0700 to 1900 on four of the four dates (12/31/24, 01/07/25, 01/21/25, 01/28/25) chosen as a sample from her extended stay from 12/29/24 to 02/05/25:
*12/31/24 - 0800 - "lying on right side", next documentation 2000 - "pillow support", "lying on right side". No other repositioning documented.
* 01/07/25 - 1100 - "lying on left side", next documentation 2000 - "pillow support". No other repositioning documented.
* 01/14/25 - 0600 - "lying on left side", next documentation 2026 - "lying on right side". No other repositioning documented.
* 01/21/25 - 0805 - no documentation under "Repositioned" or "Positioning Frequency"; next documentation 2000 - "pillow support", "semi fowlers", "lying on right side". No other repositioning documented.
* 01/28/25 - 0816 - "pillow support"; next documentation 2020 - "pillow support". No other repositioning documented.
* 02/04/25 0906 - "pillow support", "high fowlers"; next documentation 1600 - "activity completed", "other", "repositioned"; 1830 - "pillow support", "semi fowlers". No other repositioning documented.

A review of patient #11's medical record revealed a similar lack of documentation on the Mobility Flowsheet for 0700 to 1900 on 1/24/25, 1/25/25, and 1/26/25 related to her admission from 01/16/25 to 01/27/25:
* 01/24/25 - 0735 - "semi fowlers, pillow support,"; next documentation 1700 - "semi fowlers". No other repositioning documented.
* 01/25/25 - 0800 - "repositioned left side". No other repositioning documented.
* 01/26/25 - 0800 - "left side"; next documentation 1957 - "lying on side". No other repositioning documented.

In an interview with Staff #6, they stated "All staff should document patient care." They also shared there are times the documentation is not recorded even though the care was provided."
In an interview with Staff #7, they stated "...everyone can document but the nurse [helping the CNA] is normally the one that does it."
In an interview with Staff #8, they shared that all staff are required to document patient care when performed; and that if the nurse is assisting, the nurse will normally document."

In an interview on 3/25/25 with staff # 3 & #4 the above findings were confirmed.

Based on interviews, a review of facility policies, and guidelines from the Centers for Disease Control (CDC), the facility failed to avoid potential sources of infection by not maintaining a clean and sanitary environment.

Findings were:
Review of the Facility Policy Titled "Standard Precautions - CO-ICP-04-06 - Last Approved Date: 11/17", addresses associates' responsibility for disinfecting equipment. See relevant excerpt below:
"8. Reusable EQUIPMENT/DEVICES: All reusable equipment/devices will be appropriately disinfected or sterilized before patient use ...
c. Equipment and devices that do not touch the patient or that only touch intact skin of the patient will be cleaned with a detergent or disinfectant as indicated by the manufacturer ...."

A Review of the Center for Disease Control's (CDC's) Healthcare Infection Control Practices Advisory Committee "Guidelines for Disinfection and Sterilization in Healthcare Facilities. 2008;" last updated June 2024, found at: https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf - stated in part,
"3. Indications for Sterilization, High-Level Disinfection, and Low-Level Disinfection
c. Perform low-level disinfection for noncritical patient-care surfaces (e.g., bedrails, over-the-bed table) and equipment (e.g., blood pressure cuff) that touch intact skin."

In an interview with Staff #7, they stated "We wipe them [portable vital signs machine] down with bleach wipes if we have to use them on a patient in isolation, but not when taking vital signs moving from room to room."

In an interview with Staff #8, they stated "We disinfect when the equipment [portable vital signs machine] is used on isolation patients, with the bleach wipes. We don't disinfect with the bleach wipes between other patients."

In an interview with Staff #3 & #4 on 3/25/25 it was confirmed the staff did not follow policy for disinfection of shared equipment.