Observations:
Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to provide care and services regarding showering for one of five residents reviewed (Resident 2).
Findings include:
Review of facility policy, titled "Activities of Daily Living (ADLs), Supporting", without a revision date, revealed, "Appropriate care and services will be provided for residents who are unable to carry out ADLs independently."
Review of Resident 2's clinical record revealed diagnoses that included muscle weakness (weakness in the muscles causing decreasing ability to contract muscles) and malignant neoplasm of the frontal lobe (a cancerous brain tumor in the front of the brain in a portion that performs higher functions like reasoning and coordinated muscle movements).
Review of Resident 2's current care plan dated May 28, 2024, revealed a focus area of, "Resident at risk for functional decline in ADL's (activities of daily living), initiated of March 13, 2024.
Review of Resident 2's clinical record failed to reveal any showers from April 13, 2024, until May 12, 2024.
Interview with the Nursing Home Administrator on May 29, 2024, revealed that he had no further documentation of any refusals of care, and could only imagine the lack of showers may have something to do with Resident 2' pressure injuries and the treatments applied.
28 Pa code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 06/26/2024
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Resident 2 was offered a shower.
2. An audit will be completed of shower schedules for last 7 days to ensure residents were offered and provided a shower.
3. Director of Nursing or designee will provide re-education to facility nursing staff that residents are to be offered showers, unless they have different bathing preferences, and that documentation needs to be completed even if the resident refuses to be bathed.
4. A Quality Assurance and Performance Improvement plan will be developed. DNS or designee will complete random audits of 5 resident shower schedules weekly for 4 weeks and then monthly for 2 months to ensure they are offered and provided a shower. Audit findings will be reported to the monthly QAA for review and recommendations.
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