HospitalInspections.org

Based on policy review, medical record review and interview, the facility failed to ensure patient respect and dignity were maintained by providing necessary personal care and hygiene for 2 of 3 (Patient #1 and 2) sampled patients.

The findings included:

1. Review of the facility's "GUIDELINES AND PROTOCOLS, CLINICAL" policy revealed, "...Hygiene...Patient bathed/hair combed/shaved...Daily...".

2. Medical record review for Patient #1 revealed an admission date of 8/4/19 with diagnoses that included Acute on Chronic Respiratory Failure. The patient was ventilator dependent.

Review of the Comfort and Environment flowsheets for 8/12/19 through 8/22/19 revealed no documentation bathing or personal hygiene was provided for the patient on those days.

3. Medical record review for Patient #2 revealed an admission date of 6/14/19 with diagnoses that included Respiratory Failure, Encephalopathy, Chronic Obstructive Pulmonary Disease and lung cancer. The patient was ventilator dependent.

Review of the Comfort and Environment flowsheets for 6/27/19 through 6/30/19 revealed no documentation bathing or personal hygiene was provided for the patient on those days.

4. During an interview on 8/21/19 at 11:00 AM in the training room, the facility's Quality Director stated that bathing should be performed daily and documented in the medical record daily. The Quality Director verified there was no documentation for daily bathing and personal hygiene for Patient #1 and Patient #2.

Based on policy review, medical record review and interview, the facility failed to ensure assessment of restraints was completed for 1 of 1 (Patient #2) sampled patients with restraints.

The findings included:

1. Review of the facility's "RESTRAINT AND SECLUSION" policy revealed, "...MEDICAL RECORD DOCUMENTATION AND PLAN OF CARE...Every use of restraint is to be documented in the patient's record...State observations/interventions/findings from periodic observations, to include: safety, comfort, mobility, skin integrity, food/hydration and toileting-to include removal of restraints at least 10 minutes every 2 hours..."

2. Medical record review for Patient #2 revealed an admission date of 6/14/19 with diagnoses that included Respiratory Failure, Encephalopathy, Chronic Obstructive Pulmonary Disease and lung cancer. The patient was ventilator dependent. A physician's order was documented on 6/14/19 for unsecured/unrestrained mitten restraints.

Review of Patient #2's Restraint Flowsheets from 6/14/19 through 7/1/19 revealed on 6/28/19 there was no documentation of every 2 hour restraint assessments from 6:00 AM through 7:00 PM.

3. During an interview on 8/21/19 at 11:00 AM in the training room, the Quality Director verified that restraint assessments should be performed at least every 2 hours and documented in the medical record.