Healthcare Improvement Scotland (HIS) said it had concerns about the flow of patients and capacity the Glasgow’s Southern General Hospital.
In one case a patient with dementia was moved between wards several times, against the hospital’s policy. Inspectors identified 16 areas where improvement was needed.
NHS Greater Glasgow and Clyde apologised for areas of care where standards were falling short.
The HIS inspection focussing on the care of older people at the Southern General found several positive areas at the hospital, including staff treating patients with kindness and dignity and some areas being designed to meet the needs of patients with dementia.
But it also flagged up areas of concern, including the use of “boarding” where patients are moved between wards due to pressures on beds.
This practice, which often means patients are cared for on wards outside of the specialism they should be treated in, has been severely criticised as leading to worse outcomes for patients and many medical experts have called for it to be banned.
The inspectors were told that boarding took place across the hospital.
The health board’s policy states that patients with cognitive impairment - such as dementia - should not be boarded.
But the report said: “We found that was not the case. For example, a patient with known dementia and increased confusion had several ward moves.
“Although some of these moves were due to clinical need, some were documented as being due to capacity issues in the hospital.”
Staff told inspectors that when the acute medical receiving unit was full, patients were admitted directly from A&E to other medical wards.
“While medical cover continues to be provided from the admissions unit, the ward where the patient is admitted directly to does not always get additional nursing staff,” the report said.
The inspectors said that patients could also be transferred between the Southern and Victoria Hospital and Western Infirmary in Glasgow to relieve capacity issues.
“Patients can be transferred at anytime during the day or night,” the report said.
“We were told that patients with cognitive impairment are not moved. However, we saw one patient who had a cognitive impairment was moved from Victoria Hospital during the night.”
The inspectors also identified 48 patients whose discharge from hospital was being delayed. This happens when there are waits for appropriate care to be put in place, such as a care home place or support at home.
The inspectors were told that patients were waiting up to 54 days to be allocated a social worker so an assessment of their needs could be carried out.
“This is detrimental to the patients as it can lead to issues with cognitive impairment, increased risk of infection and impact on functional ability.
“Patients should not be kept in hospital longer than they should be.
“This has a direct impact on patient flow and capacity in Southern General as it reduces the availability of beds for other patients to be admitted.”
Other issues raised by the report included incorrectly completed “do not resuscitate” forms and no evidence of care plans being used to inform the care being given on the majority of wards inspected.
Jacqui Macrae, HIS head of quality of care, said: “During this inspection, we were particularly concerned about patient flow and capacity within the hospital.
“On the majority of wards inspected we found no evidence of care plans being used to inform and evaluate the care given to patients.
“We did, however, observe friendly and polite interactions between staff and patients, with the most speaking positively about the quality of care received.”
Rory Farrelly, NHS Greater Glasgow and Clyde’s Acute Director of Nursing, said: “We are pleased to note that the inspection team observed friendly and polite interactions between staff and patients, with the most of the patients interviewed speaking positively about the quality of care received.
“However we are sorry that in a number of areas we are still falling short of the standards expected in all our hospitals.
“Clearly we need to reinforce some of our policies with staff and provide additional training where required.”