Observations:
Based on observation, clinical record review and staff interview it was determined that the facility failed to ensure a resident unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for one of fifteen residents reviewed (Resident 12).
Findings Include:
Activities of Daily Living (ADL's- a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, other personal hygiene and mobility).
Review of Resident 12's clinical record revealed diagnoses that included hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and cerebral vascular accident (a stroke, also referred to as a cerebral vascular accident (CVA) or a brain attack, is an interruption in the flow of blood to cells in the brain).
An observation and interview with Resident 12, on May 14, 2024, at 9:11 AM revealed the resident in the room and found to have significant facial hair. The facial hair was most prominently observed on the upper lip and chin areas.
The interview with Resident 12 revealed feeling "depressed" regarding the amount of facial hair and stated she would accept staff assistance with removing the hair from her face.
Review of Resident 12's interdisciplinary plan of care revealed impaired function with activities of daily living due to medical diagnoses. However, no documentation regarding Resident 12's refusal of personal hygiene care, including shaving.
An interview with the Director of Nursing (DON), on May 14, 2024, at 10:01 AM revealed Resident 12 is believed to have a condition that promotes excessive hair growth. The interview also revealed Resident 12 is documented to have last been shaved by staff on April 28, 2024.
An additional interview with the DON, on May 15, 2024, at 2:50 PM revealed Resident 12 was reapproached, and staff assisted the resident with shaving her facial hair.
A final interview with the DON, on May 16, 2024, at approximately 11:30 AM revealed the facility had no additional information to provide regarding the prominent amount of facial hair found during the interview with Resident 12 on May 14, 2024.
28 Pa. Code 211.12 (d) (5) Nursing services
| | Plan of Correction - To be completed: 06/13/2024
The statement/s made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency/s herein.
To remain in compliance with all Federal and State regulations, the facility has taken, and will continue to take the actions set forth in the following plan of correction.
The following plan of correction constitutes the center's allegation of compliance. The alleged deficiency cited has been / or will be corrected by the date/s indicated.
The facility is committed to taking all actions necessary to remain in substantial compliance with the Federal and State regulations.
The plan of correction addresses our intentions to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psycho-social well-being.
F 0677
No other residents were affected by this deficiency.
On May 15, Resident 12 was approached regarding shaving and Resident 12 declined.
When staff approached a second time, Resident 12 agreed to have staff shave her.
Resident 12's plan of care has been updated to reflect resident's tendency to refuse staff's multiple attempts to shave resident.
Resident 12's Point of Care documentation has been updated to show refusal as an option for staff when multiple attempts are made, without success.
The facility does not have any other residents who routinely, or otherwise, refuse assistance with shaving and care givers offering and providing ADL care related to facial hair.
DON and/or designee performed a visual assessment, on May 15th, on all remaining residents and found no concerns related to unwanted facial hair as communicated by those residents capable of expressing their choice/preferences.
For those residents unable to express their preferences, related to facial hair, no further concerns were identified by the clinical staff.
DON and/or designee will in-service care givers on day shift and evening shift on the expectation of documenting resident 12's ADL care specific to shaving and the need for staff to make multiple attempts when Resident 12 refuses initial attempts. The in-service will also include an overall expectation of shaving/grooming facial hair for all residents per resident's and/or family personal preferences and the need for multiple attempts if necessary.
DON and/or designee will perform 2 random audits of Point of Care documentation per week for one month, then 2 random audits twice per month for two months, for the frequency of residents' acceptance for ADL care specific to shaving.
The results of the audit will be submitted to the QAPI Committee monthly, for the next 3 months, for review and determine if need for further action/additional auditing/staff education is necessary on behalf of the residents.
Facility alleges substantial compliance on 6/13/2024
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