Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 673074 (X3) Date Survey Completed 02/01/2022
Name of Provider or Supplier Temple Rehabilitation Hospital Street Address, City, State 23621 Se H.K. Dodgen Loop, Temple, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0386 ORGANIZATION OF NURSING SERVICES
CFR(s): 482.23(a)

The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital.


This STANDARD is not met as evidenced by:
Based on a review of the clinical record and an interview with staff, the director of the nursing service failed to be responsible for the operation of the service, as facility expectations regarding patient hygiene were not followed. Findings were: A review of the clinical record for patient #1 revealed that patient #1 was admitted on 9-16-21 and discharged on 10-13-21. Baths were noted on the following dates: * 9-18-21 * 9-21-21 * 9-23-21 * 9-24-21 * 9-27-21 * 10-3-21 * 10-7-21 * 10-9-21 * 10-10-21 * 10-11-21 * 10-12-21 * 10-13-21 **No other baths were documented during patient #1's stay.** In a telephone interview with staff #2 on 2-1-22, staff #2 was asked what the facility expectation was for patient bath/shower frequency. Staff #2 stated that the expectation was that patients would receive a bath/shower at least every other day and more often if they asked for one. She stated that the even-numbered rooms got baths/showers on even days (2nd, 4th, 6th, 8th etc) and that odd-numbered rooms got baths/showers on odd days (1st, 3rd, 5th, 7th etc). The above was confirmed in an interview with the CEO and other administrative staff on 2-1-22.