bed elevated each shift, and 28% were not documented
to have good pain control. Because these patients were
not on a ventilator, and not identified as high risk for
pneumonia, they did not reliably receive preventive care
interventions.
Kalisch, Landstrom, and Williams (2009) found an
alarming amount of missed or undocumented care (as
high as 70%) across hospital systems in their study of
various types of missed care. They went on to define
missed nursing care as a basic nursing error of omission.
Based on the missed or undocumented nursing care found in this analysis, a pilot study was launched
to (a) determine the effectiveness of reliably delivered
oral care in reducing NV-HAP and (b) inform a systemwide
roll-out of effective oral care interventions to reduce
NV-HAP.