| 2309 |
SPRINGDALE HEALTHCARE CENTER |
425169 |
146 BATTLESHIP ROAD |
CAMDEN |
SC |
29020 |
2017-03-09 |
312 |
E |
0 |
1 |
G49I11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews the facility failed to ensure 4 of 32 sampled resident's (R) R17, R81, R161 and R158 who were unable to carry out activities of daily living without assistance received the necessary services to maintain good grooming and personal hygiene. Findings included: 1. Resident (R) R17 was admitted to the facility on [DATE] with the following pertinent [DIAGNOSES REDACTED]. Review of R17's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated that under Section C, the assessment specified the resident had a score of 08 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had a moderate cognitive impairment. Under Section G, the assessment identified that R17 required extensive assistance of one for personal hygiene. According to the Activities of Daily Living (ADL) care plan dated 2/7/17 identified the following problem, R17 required assist with ADL's related to forgetfulness. The goal was to provide the resident with his preferred routines. The pertinent approach was; include resident preferences in rendering care and services. Observation on 3/6/17 at 1:25 p.m. R17 was sitting in the #100 hall dining room at the table. He had long bushy eyebrows, his hair was sticking out the side of his hat, and he had a scraggly bread and mustache. Observation on 3/07/17 at 8:50 a.m. R17 looked unkempt, his eye brows were long, and sticking upward, he had a full beard and mustache that were not trimmed or combed and his hair was not combed. Review of R17's Central Information Tool (a report used by nursing staff to quickly identify the resident's needs) provided on 3/8/17 indicated R17 did not have a heading under ADL assistance for personal hygiene. There was no information on the form to identify what R17's personal hygiene preference were. Review of the certified nursing assistant (CNA) - ADL Tracking Form, for the month of 3/17 for the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shift identified that the R17 required extensive assist of one person for personal hygiene (how a resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands). According to the documentation resident received assistance for personal hygiene tasks on the 7-3 and 3-11 shifts daily. Review of the Progress Notes dated 2/16/17 through 3/6/17 revealed no documentation regarding the resident's refusals of cares. It was noted that he required assist of one for ADL's and if he became resistive then assist of two persons was needed for safety. Interview on 3/7/17 at 8:50 a.m. R17 stated when asked that he preferred to be clean shaven, he said he use to shave daily. On 3/7/17 at 9:45 a.m. R17 stated that he needs help with grooming and he prefers to be clean shaven. On 3/8/17 at 9:05 a.m. R17 was noted to be clean shaven, except he had a mustache. When asked if he wanted to keep it, he said he did not care. On 3/8/17 at 5:14 p.m. R17 stated when asked, that most of the time he likes to be clean shaven but the mustache was ok, he would keep it for a while. 2. R81 was re-admitted to the facility on [DATE] with the following pertinent [DIAGNOSES REDACTED]. Review of R81's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated that under Section C, the assessment specified the resident had a score of 4 out of 15 on BIMS, which indicated the resident had a severe cognitive impairment. Under Section G, the assessment identified that R81 required limited assistance of one for personal hygiene. According to the ADL care plan dated 5/24/16 identified the following problem, R81 required limited assist with ADL's (bathing, dressing, hygiene, etc.) and at times requires rest breaks as he gets short of breath with activity. The goal was that R81 would be clean, dry, and odor free as well as participate as able during cares and to provide the resident with his preferred routines. The pertinent approach was; include resident preferences in rendering care and services. On 3/6/17 at 4:45 p.m. R81 was observed to have a beard and mustache growing as well as hair down his neck. On 3/07/2017 at 12: 52 p.m. R81 was observed sitting in the dining room he remained unshaven. Review of R81's Central Information Tool provided on 3/7/17 indicated R81 did not have a heading under ADL assistance for personal hygiene. There was no information on the form to identify what R81's personal hygiene preference were. Review of the certified nursing assistant (CNA) - ADL Tracking Form, for the month of 3/17 for the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shift identified that the resident required limited assist of one person for personal hygiene. According to the documentation resident received assistance for personal hygiene tasks on the 7-3 and 3-11 shifts daily. Review of the Progress Notes dated 2/16/17 through 3/6/17 revealed no documentation regarding the resident's refusals of cares. Interview on 3/6/17 at 4:46 p.m. R81 stated that he likes to be clean shaven. He said that they are supposed to shave him daily but they do not. On 3/7/17 at 3:09 p.m. R81 stated to this surveyor and licensed practical nurse (LPN) 4 that he did not need to shave every day, he thought every other day would be ok. He discussed that he does need help shaving as his arms get tired. 3. R161 was re-admitted to the facility on [DATE] with the following pertinent [DIAGNOSES REDACTED]. Review of R161's 60 day PPS (Perspective Payment System) MDS dated [DATE], indicated that under Section C, the assessment specified the resident had a score of 14 out of 15 on BIMS, which indicated the resident had no cognitive impairment. Under Section G, the assessment identified that R81 was dependent of one for personal hygiene. According to the ADL care plan dated 1/3/17 identified the following problem, R161 required assistance with ADL's related to weakness, and limited range of motion. The goal was that R161 would be clean, dry, and odor free as well as participate as able during cares. The pertinent approach was; ensure that resident was bathed, dressed, and groomed appropriately at all times. On 3/6/17 at 3:03 p.m. R161 was observed to have a beard and mustache growing as well as long nose hairs. His nails were long and had debris underneath. On 3/07/17 at 8:20 a.m. R161 was observed lying in bed he was still unshaven and his nails remained long and unclean. On 3/8/17 at 9:13 a.m. R161 nails remained long and unclean. He was clean shaven although his nose hair was still long. Review of R161's Central Information Tool provided on 3/7/17 indicated R161 did not have a heading under ADL assistance for personal hygiene. There was no information on the form to identify what R161's personal hygiene preference were. The form did identify that he had bilateral hand contractures. Review of the certified nursing assistant (CNA) - ADL Tracking Form, for the month of 3/17 for the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shift identified that the resident was dependent of one to two persons for personal hygiene. According to the documentation resident received assistance for personal hygiene tasks on the 7-3 and 3-11 shifts daily. Review of the Progress Notes dated 3/1/17 through 3/7/17 revealed no documentation regarding the resident's refusals of cares. Interview on 3/6/17 at 3:03 p.m. R161 stated that he needed a shave now as he liked to be clean shaven. He also stated that his nails were long and unclean. On 3/7/17 at 12:45 p.m. R161 was observed lying in bed receiving meal assistance from a CN[NAME] He remained unshaven and his nail were still long and unclean. On 3/8/17 at 9:13 a.m. resident stated he got shaved yesterday and that he had told them that this surveyor had asked him about his shaving preferences. He stated he finally got someone to shave him and he was happy. He acknowledged that his nails were still long and unclean. On 3/09/2017 at 9:00 a.m. the DON acknowledged that the resident's finger nails were unclean and long. She confirmed that it was the expectation that nail care be done with the resident's daily bath whether it be bed bath or shower. R161 agreed to have staff cut his nails and informed the DON that he liked to be clean shaven. On 3/7/17 at 3:00 p.m. CNA3 stated that she shaved R81 today and that he usually tells her when he wants to be shaved. She stated she was not aware that he preferred to be clean shaven and that he would like to shave every day. On 3/7/17 at 4:18 p.m. the CNA2 stated she worked second shift (3-11 p.m.). She discussed that she reviews her daily assignments and for the resident that she was assigned she was expected to document that they had a shower, and if they refused, the nurse was to be notified. If the resident refused the nurse then nursing called the family and documented the refusal in the nurse's notes. She discussed that documentation needed to be signed on the ADL sheet and on the assignment sheets. The policy is that that CNA staff document in both places every day. On 3/7/17 at 3:05 p.m. LPN4 stated that they have been working on a new sheet which identified the resident's preferences, but they have not started using it yet. She discussed that the CNA - ADL Tracking Form, included shaving and nail care was expected. She discussed that if the resident refused to be shaved, nursing should be notifying as well as the family and the refusal should be documented by the CNA and the nurse. She confirmed that it was the expectation that staff try to honor the resident's previous life preferences when possible. On 3/7/17 at 4:23 p.m. during an interview with Director of Nursing (DON) stated that her expectations was that on the residents assigned shower day they received a shower and if they refuse on that day and refused a bed bath as well the CNA was to notify the nurse. The nurse was to confirm with the resident that they declined see if she could get them too agree, if the resident continued to decline the nurse notified the family and documented the refusal in the progress notes. She discussed that if the resident refused, or received a shower or a bed bath the information should be documented on the shower sheets it was never to be left blank. On 3/8/17 at 9:57 a.m. staffing Development Coordinator (SDC) stated that groomed meant, oral care, nail care, and shaving for men/women. Training for ADL care was done on hire, annually and as needed. Residents were to be shaved daily, nail care completed on their shower days and for those who did not get a shower but a bed bath, nail care and grooming also needed to be completed. Even if the resident refuses a shower it is the expectation that the other components be completed. The resident's preferences should be care planned and placed on the Kardex. She stated that they have been transitioning with new corporation and they are working on developing new processes and forms. On 3/9/17 at 8:40 certified nursing assistant (CNA) 4 stated she was new but she tries to take her time with the residents and that it was the expectation that the resident be groomed (hair combed, shave, teeth brushed) and clothing be clean and fitting. 4. Review of the medical record for R158 revealed that he was admitted to this facility on 10/12/15 with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Per the physician's orders [REDACTED]. Observation of R158 on 3/7/17 at 3:05 p.m. revealed that he was seated in his wheelchair, dressed and waiting for staff to assist him to the afternoon activities. R158 was observed to have multiple skin tears and bruising on his forearms. He also had finger nails that were protruding beyond the end of his fingers and they were yellow with a dark debris underneath. An interview with R158 on 3/17/17 at 3:05 p.m. revealed he was unhappy with his grooming. He stated that he did not like long finger nails and he had asked the staff repeatedly to trim and groom his fingernails, to no avail. He stated that staff said, we are not accountable to you when he requested that they cut his finger nails. R158 added that he could not cut his nails independently, and required the assistance from staff. R158 added that he received a daily bed bath and he believed that staff were to cut and trim is nails during that time. He added that his long nails could be creating bruising and skin tears on his forearms. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the facility coded R158 as a 15 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated that he was not cognitively impaired. Review of Section G on the MDS reflected how the facility coded R158 for functional status. He was coded a 3 out of 4 which reflected that he required extensive assistance with dressing, toileting and personal hygiene. Review of the ADL Functional/ Rehabilitation care plan for R158 dated 8/2/16 and updated quarterly, revealed that he is was able to make his wants and needs known and he had bilateral amputations. He had a prosthesis for his left leg but he did not have one for his right leg. R158 was incontinent of bowel and bladder and he was Dependent on staff for toilet, hygiene care, bathing and dressing. The Goal documented on the care plan read, Resident will be clean, dry & odor free of bowel incontinence and foley (sic) cath (catheter) care q (every) shift. and the Target Date was 4/23/17. One of the approaches listed on the care plan, which was dated 8/2/16 read, Ensure patient is bathed, dressed, and groomed appropriately at all times. Review of the CNA (Certified Nursing Assistant) - ADL (activity of daily living) Tracking Form dated (MONTH) (YEAR) revealed that R158 was also coded as a 3 out of 4 for toilet use, personal hygiene, and bathing which indicated that he required extensive assistance from staff for those ADLs. An interview with the Certified Nursing Assistant (CNA) 1 on 3/7/17 at 3:15 p.m. revealed that she had been assigned to assist R158 with his ADLs. CNA 1 added that she had assisted him on this day with his bathing, grooming and dressing needs. When interviewed about his nails, CNA 1 stated that she had noticed his long finger nails but did not know that she was supposed to trim and clean his nails. She believed that nursing was to perform that function for R158. An interview with the Licensed Practical Nurse (LPN) 2 on 3/7/17 at 3:30 p.m. revealed that it was the CNAs who were supposed to trim and clean each residents' nails, not nursing. When interviewed about trimming and cleaning the finger nails of diabetic residents, LPN 2 stated that the CNAs would need to be more careful when assisting them with their ADLs. An interview with the Unit Manager, LPN 4 on 3/7/17 at 3:45 p.m. revealed that each resident should have their nails cleaned and groomed during their shower or bath at least 2 times each week. She added that each resident had a Central Information Tool (CIT) that provided their needs and preferences to the CNAs in order to help them implement each residents care plan appropriately. LPN 4 stated that the CIT was basically the CNA's care plan for each resident. There was no documentation that reflected that R158's finger nails had been trimmed and groomed for the month of (MONTH) (YEAR). Review of the CIT for R158, revealed that it was incomplete and did not contain most of the pertinent information about his daily needs. The CIT included personal information as well as clinical information about R158. The facility failed to include important information on R158's CIT's to ensure that his ADL needs would be provided. They failed to provide the following pertinent information on the CIT: Diabetic status Oral care needs Special needs Bowel and Bladder care Pain management Identified risks ([MEDICAL TREATMENT], bleeding, falls, etc.) Adaptive devices (prosthesis) Mood/behaviors ADL assistance needs Bathing Preferences relative to day and time. Review of the directions relative to how to complete a CIT for each resident revealed the following information: Objectives: 1) To provide consistent communication of resident needs . .Standard: 1) All residents in the facility will have a CIT completed on admission and updated throughout the stay in the facility . .5) The admission director or facility designee will complete the following on admission: name, diagnosis, date of admission, admission goal, physician, discharge plan, allergies [REDACTED]. .7) the remainder of the CIT will be completed within 24 hours of admission . .9) The CIT will be updated on an ongoing basis when changes occur . An interview with the Administrator on 3/7/17 at 4:00 p.m. revealed that after each resident was assessed as to their required daily needs and preferences relative to their ADL functions, the facility staff were to develop a plan of care to ensure that each resident would receive the services necessary to ensure they could maintain their grooming practices. She added that the facility failed to ensure that R158 received the care and services he required relative to his hygiene and grooming needs. |
2020-09-01 |