HospitalInspections.org

Based on document review and interview, nursing failed to document patient care in regard to providing and recording patient showering in 10 of 10 patient medical records reviewed (P1-P10).

Findings include:

1. No policy was provided that indicated specifically where patient showering, or refusal to shower was documented in the patient medical record.

2. Review of the Medical Records (MR's) for patients P1-P10 indicated no specific documentation of patients receiving or refusing showers.

3. In interview on 04/01/2025 at approximately 1300 hours, S3, Chief Executive Officer, indicated and confirmed that no policy existed that specifically requires staff to document showering activities in the MR. The facility uses the 12 hour (shift) nursing assessment that records patients participation of self care for activities of daily living (only patients capable of self-care are admitted), physical appearance, skin condition, and bowel movements.