HospitalInspections.org

Based on document review and interview, the facility failed to ensure assistance with showers/bathing for 1 of 10 medical records reviewed. (Patient #1)

Findings include;

1. Facility policy titled "Patient Personal Care", PolicyStat ID: 12197137, approved 8/2022 indicated the following: "PROCEDURE: Definition CMS defines ADLs as activities related to personal care, which includes the following: Bathing/showering; Dressing; Getting out in and out of bed/chair; Walking; Using the toilet; Eating. Education: All patients will be provided education upon admission regarding the process for ADLs, including but not limited to: Unit routine for bathing/showering, toileting, meals, etc. Bathing/showers will be offered daily."

2. Review of Patient #1's medical record indicated the following:
(A) The patient was admitted on 7/14/24 at 3:00 p.m. and was discharged to Facility #2 (acute care facility) on 7/30/24.
(B) The patient's medical record lacked documentation of showers/baths and/or refusals for the following dates: 7/14/24, 7/15/24, 7/16/24, 7/19/24, 7/20/24, 7/21/24, 7/22/24, 7/23/24, 7/24/24 and 7/25/24. A total of 10 out of 17 days.

3. During an interview with A5 (Director of Nursing) on 8/2/24 at 2:00 p.m., A5 verified the lack of documentation in Patient #1's medical record for showers/baths and/or refusals for 10 of 17 days reviewed.