§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
|
Observations:
Based on clinical record review and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents who are dependent on staff for assistance with these activities of daily living for two of four residents reviewed (Residents 2 and 3).
Findings include:
Review of Resident 2's clinical record documented diagnoses that included anxiety (a feeling of worry, nervousness, or unease), depression (feelings of severe despondency and dejection), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills, eventually affecting the ability to carry out daily tasks), vascular dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), bipolar (a mental health condition alternating periods of elation and depression), and hallucinations (a false perception of sight, sound, smell tasse or touch that seems real but has no externa stimulus).
Further clinical record review revealed that Resident 2 was dependent, one-person physical assistance, for bathing/showering and was scheduled for showers on Tuesdays and Fridays on day shift.
Review of task documentation revealed she received a bed bath, not a shower, on October 20th, 22nd, 23rd, and 24th, 2025, and was washed up at the sink on the 21st. The clinical record failed to include documentation for bathing on October 28th and 31st, 2025, and November 4th, 7th, and 11, 2025.
During an interview with the Director of Nursing (DON) on November 19, 2025, at 3:15 PM, it was revealed that the family voiced concerns that included Resident 2 was not receiving showers. In response to the concern, the facility obtained statements from staff. Statements revealed Resident 2 would refuse to get out of bed, refused showers, and at times morning care was provided by night shift.
Resident 2 was on Occupational Therapy (OT) and the DON witnessed OT providing a shower on one instance: November 14th, 2025.
Review of Resident 3's clinical record documented diagnoses that included dementia with behavioral disturbances, vascular parkinsonism (cause by brain damage and symptoms may include gait disturbance, slowness, stiffness and cognitive issues), and adjustment disorder with mixed anxiety and depressed mood with disturbance of emotions and conduct.
Further clinical record review revealed that Resident 3 was dependent, two-person physical assistance due to combativeness, for bathing/showering and was scheduled for showers on Tuesdays and Fridays on evening shift.
Review of task documentation revealed she received a shower on October 31st, 2025, and was washed up at the sink on October 28th, 2025, and November 7th, 2025.The clinical record failed to include documentation for bathing on October 21st and 24th, 2025, and November 4th, 11th, and 14th, 2025.
During an interview with the Nursing Home Administrator and DON on November 19, 2025, at 3:15 PM, it was revealed she felt that Resident 3 has had bathing completed but staff hadn't documented it. It was also revealed that Resident 3 had verbal and physical behaviors, as well as being up for several days. If the Resident is sleeping after long periods of being awake, the staff will let her sleep.
28 Pa code 211.12.(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 12/31/2025
1. R2 was discharged from the facility. R3s care plan has been updated to receive bed baths.
2. Facility will complete audit of residents' showers over the last 2 weeks to ensure residents are receiving showers as scheduled.
3. Re-education will be provided to nursing staff regarding completion of showers, and documentation of ADL care. Residents who prefer bed baths will be care-planned according to their preference.
4. DON/designee will audit 10 residents' showers weekly x4 weeks, then 10 monthly x2 months to ensure showers or bed baths are completed as preferred. Results of audits will be reviewed at QAPI to ensure compliance and quality assurance.
|
|
