HospitalInspections.org

Based on interview and record review facility staff failed to ensure nursing staff provide/offer hygiene cares for patients in 4 of 10 medical records reviewed (Patient (Pt) #1, 6, 9, 10), in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure titled, "Showering and Bathing Standards" (no date) revealed the following:
-"The Nursing staff are ultimately responsible for all bathing and showering of patients. Therapy staff may include showering or bathing as a part of their patient's therapeutic treatment. Registered Nurses (RN), LPN (Licensed Practical Nurse), CNAs (Certified Nursing Assistant), and therapy staff can complete bathing and showering tasks."
-"Nursing is responsible for the bathing or showering of all patients at minimum every other day."
-"All bathing or showers will be documented within the EMR (electronic medical record)."
-"...bathing or showering removes dirt, perspiration, bacteria, and dead skin as well as promotes blood circulation."

Review of policy and procedure titled, "Patient Oral Care" Version 1 dated 10/09/2023 revealed, "Oral care will be provided to all patients...Clean healthy mouths contribute to a sense of well-being, increases patient's willingness to take hydration and food, and contributes to quality of life and well-being."

Review of Pt #1's medical record revealed Pt #1 was admitted to the rehabilitation hospital on 08/07/2023 at 2:58 PM, and discharged home on 08/25/2023.

Review of Pt #1's CNA shift assessments and Occupational Therapy (OT) Notes from 08/10/2023 through 08/16/2023 revealed there was no documented evidence of Pt #1 having a shower or bath 08/11/2023 through 08/16/2023 (6 days); and no documented evidence of Pt #1 receiving oral care on 08/12/2023 and 08/13/2023.

Review of Pt #6's medical record revealed Pt #6 was admitted to the rehabilitation hospital on 010/06/2023 at 2:58 PM, and was in the hospital at the time of the medical record review beginning on 10/10/2023 at 2:35 PM.

Review of Pt #6's CNA shift assessments and OT Notes from 10/06/2023 through 10/10/2023 revealed there was no documented evidence of Pt #6 having a shower or bath from 10/07/2023 through 10/09/2023 (3 days).

Review of Pt #9's medical record revealed Pt #9 was admitted to the rehabilitation hospital on 10/04/2023 at 5:55 PM, and was in the hospital at the time of the medical record review beginning on 10/10/2023 at 3:20 PM.

Review of Pt #9's CNA shift assessments and OT Notes from 10/04/2023 through 10/10/2023 revealed there was no documented evidence of Pt #9 having a shower or bath from 10/06/2023 through 10/09/2023 (4 days); and no documented evidence of Pt #9 receiving oral care on 10/09/2023.

Review of Pt #10's medical record revealed Pt #10 was admitted to the rehabilitation hospital on 10/03/2023 at 12:00 PM, and was in the hospital at the time of the medical record review beginning on 10/10/2023 at 3:50 PM.

Review of Pt #10's CNA shift assessments and OT Notes from 10/03/2023 through 10/10/2023 revealed there was no documented evidence of Pt #10 having a shower or bath from 10/03/2023 through 10/05/2023 (3 days) and 10/8/2023 through 10/09/2023 (2 days); and no documented evidence of Pt #10 receiving oral care on 10/04/2023, 10/06/2023, and 10/08/2023.

Per interview with Chief Nursing Officer (CNO) C, while reviewing medical records on 10/10/2023 beginning at 12:15 PM, CNO C stated that patients should receive a bath or shower at least every other day and oral care daily. CNO C stated that this should be documented in the medical record by the staff that performed the hygiene cares. CNO C confirmed there was no documented evidence of a shower or bath and oral care completed in the above medical record findings.