HospitalInspections.org

Based on review of the facility policy, medical record review, and staff interviews the survey revealed the nursing staff failed to maintain a care plan for 10 of 10 patients admitted for impaired ability to perform self care activities of daily living (bathing and monitoring of meal consumption). (Patient #2, #3, #7, #8 ,#10, #1, #4, #5, #6 and #9).

The findings included:

Review on 01/10/2024 of the facility policy "Care Planning" revised 09/21/2023 revealed "PURPOSE To define a mechanism to document an individualized interdisciplinary Plan of Care (IPOC) for the patient...Definitions Care planning involves planning for patient's needs from the perspective of the patient...includes but is not limited to physical needs, cognitive needs, functional needs...POLICY...plan of care developed, which will be based on his/her assessed individual needs...IDT (Interdisciplinary Team) members have primary responsibility for the plan including goal setting as per their discipline and area of expertise...Each body system or functional area with identified problems will be followed by specific interventions designed to meet the needs of the patient..."

1. Review on 01/09/2024 of an open medical records revealed Patient #2 was an 83-year-old male admitted on 01/01/2024 at 1220 for abnormalities of gait, ADL's (Activities of daily living). Review of the History and Physical completed 01/02/2024 at 1212 by the admitting Medical Doctor (MD) revealed "...Impression and Plan:...Risk of complications (and plans to mitigate them):..Nutrition: We will assess the patient's intake and add nutritional supplements as recommended per dietician...Current Level of Function...Basic ADL's Moderate Assistance: Bathing..." Review of the Interdisciplinary Plan of Care documented on 01/02/2024 at 1508 revealed "...Functional Status Self Care...Eating, Independent...Shower,Bathe Self: Partial/Moderate assistance..." Record review failed to reveal documentation of percent of meal consumption on 01/02/2024, 01/03/2024, 01/04/2024, 01/06/2024 and 01/08/2024 (5 of 7 days). Record review revealed the intervention of provision of a bath/shower was a shared task between Occupational Therapy (OT) and Nursing. Review revealed OT would provide Nursing staff with a daily list of scheduled baths to be performed by the OT staff. Record review failed to reveal documentation of a bath or shower offer or patient denied on 01/03/2024, 01/06/2024, 01/07/2024 (3 of 7 days).

Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation.

Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

2. Review on 01/09/2024 of a closed medical record revealed Patient #3 was a 70-year-old male admitted on 11/14/2023 at 1540 for abnormalities of gait, ADL's. Review of the History and Physical completed 11/15/2023 at 1140 by the admitting MD revealed "..Impression and Plan:...Risk of complications (and plans to mitigate them):..Nutrition: We will assess the patient's intake and add nutritional supplements as recommended per dietician...Current Level of Function...Basic ADL's: Supervision Comments: grooming/Set up with oral hygiene while sitting up in cardiac chair position. Basic ADL's: Minimal Assistance Comments: Proximal aspect of LEs (lower extremities) with CGA (contact guard assistance) and min cues for task completion..." Review of the Interdisciplinary Plan of Care documented on 11/15/2023 at 1157 revealed "...Functional Status Self Care...Shower,Bathe Self: Partial/Moderate assistance...Nutrition...Goals-Maintain/achieve nutritional requirements..." Record review of Nutrition Assessment on 11/15/2023 at 1627 documented by the Dietician of the facility revealed "...Nutrition Monitoring and Evaluation Monitor nutritional status, Monitor fluid and PO (oral intake of liquid or solid food) intake..." Record review failed to reveal documentation of percent of meal intake on 11/18/2023, 11/19/2023, 11/20/2023 and 11/21/2023 (4 of 7 days). Record review failed to reveal documentation of bath/shower offer or patient denial on 11/18/2023, 11/19/2023, 11/20/2023 and 11/21/2023 (4 of 7 days). Review revealed Patient #3 was discharged on 11/28/2023 at 1530 home with Home Health Agency supportive services.

Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation.

Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

3. Review on 01/09/2024 of an open medical record revealed Patient #7 was a 75-year-old male admitted on 12/23/2023 at 1440 for Stroke with right hemiparesis (muscle weakness or partial paralysis on one side of the body). Review of the History and Physical completed by the admitting MD on 12/24/2023 at 1412 revealed "...Risk of complications (and plans to mitigate them):...Nutrition: We will assess the patient's intake...Current Level of Function...Basic ADL's: Maximal Assistance Comments: UB (upper body)/LB (lower body) bathing..." Review of the record failed to reveal documentation of a bath/shower offer or patient denial on 01/01/2024, 01/03/2024, 01/05/2024 and 01/06/2024 (4 of 7 days). Review of Nutrition Assessment completed on 12/23/2023 at 1637 revealed "... Nutrition Monitoring and Evaluation Monitor nutritional status, Monitor fluid and PO intake..." Review failed to reveal documentation of percent of meal intake on 01/02/2024, 01/03/2024, 01/04/2024 (3 of 7 days).

Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation.

Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

4. Review on 01/11/2024 of an open medical record revealed Patient #8 was a 72-year-old female admitted on 12/25/2023 for abnormalities of gait, ADL's. Review of the History and Physical completed 12/26/2023 at 1032 by the admitting MD revealed "..Impression and Plan...Risk of complications (and plans to mitigate them):..Nutrition Monitoring and Evaluation Monitor nutritional status, Monitor fluid and PO intake..." Review of the Interdisciplinary Plan of Care documented on 12/25/2023 at 1400 revealed "...Eating: Supervision or touching assistance...Shower, Bathe Self: Dependent...Self Care Plan...Therapeutic PO (oral) feeding..." Record review failed to reveal documentation of percent of meal consumption on 12/31/2023, 01/03/2024 (2 of 7) day. Review failed to reveal documentation of bath/shower offer or patient denial on 12/30/2023, 12/31/2023 (2 of 7 days).

Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation.

Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

5. Review on 01/10/2024 of a closed medical record revealed Patient #10 was 67-year-old male admitted on 11/24/2023 at 1752 for impaired mobility and ADL's. Review of the History and Physical completed 11/24/2023 at 1750 by the admitting MD revealed "...Current Level of Function...Basic ADL's: Moderate Assistance UB (upper bathing) Basic ADL's Maximal Assistance LB (lower body)..." Review of the Interdisciplinary Plan of Care documented on 11/24/2023 at 1825 revealed "...Eating minimal assistance/supervision...Self car...Shower, Bathe supervision or touching assistance..." Review failed to reveal documentation of bath/shower offer or patient denial on 01/02/2024, 01/03/2024, 01/04/2024 and 01/05/2024 (4 of 7 days). Review failed to reveal documentation of percent of meal consumption on 01/05/2024, 01/08/2024, 01/09/2024 (3 of 7 days). Record review revealed Patient #10 was discharged home with Home Health Agency supportive services.

Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation.

Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.


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6. Review on 01/10/2024 of an open medical record revealed Patient #1 was a 66-year-old male admitted on 12/30/2023 at 1803 for abnormalities of gait, ADL's (activities of daily living), and mobility after having a stroke on 12/19/2023. Review of the History and Physical completed 12/31/2023 at 1357 by the admitting Medical Doctor (MD) revealed "... Current level of function ... Basic ACL's: ... Minimal assistance comments: set up ... Impression and Plan: ... Risk of complications (and plans to mitigate them): ... Nutrition: We will assess the patient's intake and add nutritional supplements as recommended per dietician." Review of the Interdisciplinary Plan of Care documented on 12/30/2023 at 1819 revealed "...Functional Status Self Care...Eating, setup and clean-up assistance...Shower, Bathe Self: Substantial/Maximal assistance..." Record review for the week of 01/01/2024 through 01/07/2024 failed to reveal documentation of percent of meal consumption on 01/03/2024 for the evening meal, 01/04/2024 for the evening meal, 01/06/2024 for breakfast and the evening meal. Record review revealed the intervention of provision of a bath/shower was a shared task between Occupational Therapy (OT) and Nursing. Record review failed to reveal documentation of a bath or shower offer or patient denied on 01/01/2024, 01/04/2024, 01/05/2024, 01/06/2024, and 01/07/2024 (5 of 7 days).

Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital.

Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation.

Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital.

7. Review on 01/09/2024 of a closed medical record revealed Patient #4 was a 64-year-old male admitted on 11/14/2023 as a second chance rehabilitation admission for abnormalities of gait, ADL's (activities of daily living), and mobility after a motor vehicle collision on June 2023 in which Patient #4 was diagnosed with a cervical spine injury, incomplete quadriparesis (weakness in all four extremities) at cervical vertebrae 5-6. Review of the History and Physical completed 11/15/2023 at 1108 by the admitting Medical Doctor (MD) revealed " ... Risk of complications (and plans to mitigate them): ... Nutrition: We will assess the patient's intake and add nutritional supplements as recommended per dietician." Review of the Interdisciplinary Plan of Care documented on 11/14/2023 at 1516 revealed "...Functional Status Self Care ...Eating: Supervision or touching assistance...Toileting Hygiene: Substantial/Maximal assistance..." Record review for 12/03/2023 through 12/05/2023 failed to reveal documentation of percent of meal consumption on 12/04/2023 for 3 meals. Record review for 12/31/2023 through 01/06/2024 failed to reveal documentation of percent of meal consumption on 12/31/2023 for 3 meals, 01/01/2024 for 3 meals, 01/02/2024 for 3 meals, 01/03/2024 for 3 meals, 01/04/2024 for 3 meals, 01/05/2024 for the evening meal, and 01/06/2024 for the lunch meal. Record review revealed the intervention of provision of a bath/shower was a shared task between Occupational Therapy (OT) and Nursing. Record review failed to reveal documentation of a bath or shower offer or patient denied on 12/11/2023, 12/13/2023, 12/15/2023, 12/31/2023, 01/01/2024, 01/02/2024, 01/03/2024, and 01/05/2024 (8 of 12 days).

Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital.

Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectation of the hospital.

Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation.

Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital.

8. Review on 01/10/2024 of an open medical record revealed Patient #5 was a 68-year-old male admitted on 01/03/2024 around 1830 for abnormalities of gait, ADL's (activities of daily living), and mobility after treatment for a stroke on 12/26/2023. Review of the History and Physical completed 01/04/2024 by the admitting Medical Doctor (MD) revealed Patient #5 needed minimal assistance with eating, and "Nutrition: We will assess the patient's intake and add nutritional supplements as recommended per dietician." Review of the Interdisciplinary Plan of Care documented on 01/03/2024 at 2225 revealed "...Functional Status Self Care...Eating: Supervision or touching assistance...Shower, Bathe Self: Partial/Moderate assistance..." Nutrition consult dated 01/05/2024 at 1027 revealed Patient #5 stated "I don't eat hospital food." The Dietary note revealed a plan to monitor the weight of the patient and for dietary to continue working with food preferences and encourage the patient to order out for food preferences as needed with nursing assistance. The admission weight on 01/03/2024 for Patient #5 was reported as 80.6 kg (kilograms), follow up measurements include: 80.5 kg on 01/04 and 05/2024, 80.4 kg on 01/06/2024, 78.5kg on 01/07/2024, 78.7 kg on 01/08/2024, 78.9 kg on 01/09/2024, and 78.2 kg on 01/10/2024. Record review revealed for the week of 01/04/2024 through 01/10/2024 a % of meal documented for the breakfast meal on 01/04/2024 and for the breakfast and lunch meal on 01/10/2024. While there are amount totals or refusals documented on the majority of the meals, there are 7 meals with no documentation of totals or % eaten. Record review revealed the intervention of provision of a bath/shower was a shared task between Occupational Therapy (OT) and Nursing. Record review failed to reveal documentation of a bath or shower offer or patient denied on 01/05/2024, and 01/08/2024 (2 of 7 days).

Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital.

Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital.

Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation.

Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital.

9. Review on 01/10/2024 of an open medical record revealed Patient #6 was a 67-year-old male admitted on 01/01/2024 at 1550for abnormalities of gait, ADL's (activities of daily living), and mobility after having a stroke around 12/27/2023. Review of the History and Physical completed 01/02/2024 at 1220 by the admitting Medical Doctor (MD) revealed "... Risk of complications (and plans to mitigate them): ... Nutrition: We will assess the patient's intake and add nutritional supplements as recommended per dietician. ... Current level of function ... Basic ACL's: Dependent ... Comments: Total A (assistance) ADLs." Review of the Interdisciplinary Plan of Care documented on 01/01/2024 at 1626 revealed "...Functional Status Self Care...Eating: Partial/Moderate assistance...Shower, Bathe Self: Partial/Moderate assistance..." Record review for the week of 01/02/2024 through 01/08/2024 failed to reveal documentation of percent of meal consumption on 01/04/2024 for the evening meal, 01/06/2024 for the evening meal, 01/07/2024 for breakfast and 01/08/2024 for lunch and evening meal. Record review revealed the intervention of provision of a bath/shower was a shared task between Occupational Therapy (OT) and Nursing. Record review failed to reveal documentation of a bath or shower offer or patient denied on 01/04/2024, 01/06/2024, and 01/08/2024 (3 of 7 days).

Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital.

Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital.

Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation.

Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital.

10. Review on 01/10/2024 of an open medical record revealed Patient #9 was an 82-year-old male admitted on 12/29/2023 at 1500 for right hip osteoarthritis and Parkinsons Disease. Review of the History and Physical completed 12/29/2023 at 1503 by the admitting Medical Doctor (MD) revealed "... Current level of function ... Basic ADL's: Moderate assistance ... comments: bathing, toileting ... Risk of complications (and plans to mitigate them): ... Nutrition: We will assess the patient's intake and add nutritional supplements as recommended per dietician." Review of the Interdisciplinary Plan of Care documented on 12/29/2023 at 1607 revealed "...Functional Status Self Care...Eating: Independent...Shower, Bathe Self: Substantial/Maximal assistance..." Record review for the week of 01/03/2024 through 01/09/2024 failed to reveal documentation of percent of meal consumption on 01/03/2024 for 3 meals, 01/04/2024 for 3 meals, 01/05/2024 for breakfast and the lunch meal, 01/06/2024 for the lunch and evening meal, 01/07/2024 for 3 meals, 01/08/2024 for the lunch and evening meal, 01/09/2024 for the lunch and evening meal. Record review revealed the intervention of provision of a bath/shower was a shared task between Occupational Therapy (OT) and Nursing. Record review failed to reveal documentation of a bath or shower offer or patient denied on 01/04/2024, 01/05/2024, 01/08/2024, and 01/09/2024 (3 of 7 days).

Interview on 01/10/2024 at 1234 with a Registered Nurse Supervisor of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital.

Interview on 01/10/2024 at 1355 with the Director of Therapy revealed the hospital did not have a specific bathing policy, however the process of patient hygiene was a shared responsibility with the Nursing Department. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital.

Interview on 01/11/2024 at 1112 with a Certified Nurse Assistant of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation.

Interview on 01/11/2024 at 1132 with the Chief Medical Officer of the hospital revealed daily documentation should include offer or patient denial of a daily bath/shower. Interview revealed the documentation should include the percent of meal consumption of the patient to be considered in the patient's progress evaluation. Interview revealed the medical record documentation did not meet the expectations of the hospital.
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