| 11 |
SANTA FE CARE CENTER |
325030 |
635 HARKLE ROAD |
SANTA FE |
NM |
87505 |
2019-07-19 |
677 |
D |
0 |
1 |
W7WU11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide ADL (activities of daily living) assistance for nail care for 1 (R #27) of 1 (R #27) residents reviewed for ADL's. This deficient practice has the potential to affect the dignity and health of the residents. The findings are: [NAME] On 07/15/19 at 12:24 pm, during observation, R #27 was observed with dirty and uncut fingernails. B. On 07/18/19 at 11:05 am, a second observation of R #27 revealed, R #27's nails had a black substance under her thumb nails and were not clean or cut. C. On 07/19/19 at 9:49 AM, the resident was observed in her room. Her nails were different lengths except her thump nails which were long and dirty with a black substance. Resident reported that she cuts her own nails and showed me a nail clipper. D. On 07/16/19 during record review of R #27's care plan dated 04/30/19 revealed: Focus: (Name of R #27) have an ADL Self Care Performance Deficit r/t: Progressed dementia and require staff assistance with all ADL's. Goal: (Name of R #27) will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene through the review date. Interventions: C.N.[NAME] Nursing *Praise all efforts at self-care. *TOILET USE: I require (X) staff participation to use toilet. *TRANSFER: I require (1) staff participation with transfers for my safety due to risk of falls but I will usually self-transfer since I forget to call for assistance. *Encourage me to participate to the fullest extent possible with each interaction. *SKIN INSPECTION: I require SKIN inspections on my scheduled shower days 3X per week by the CNA and once weekly by my nurse. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Nurse to document ton weekly skin assessment sheets. *BATHING: I am able to participate in bathing but require staff assistance and verbal cueing. *PERSONAL HYGIENE/ORAL CARE: I require 1 staff participation with personal hygiene and oral care. *PERSONAL HYGIENE/ORAL CARE: I require limited to extensive assistance of 1 staff with my hygiene needs. Please cue and direct me so I can participate to the best of my ability. * DRESSING: Allow me sufficient time for dressing and undressing. The task is confusing for me and I require limited to extensive assist of 1 staff. E. On 07/16/19 during record review of R #27's care plan dated 04/30/19 revealed: DX (Diagnosis) UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE (F03.90), OTHER [MEDICAL CONDITION] (A condition in which there are high levels of fat particles (lipids) in the blood.) (E78.49), HISTORY OF FALLING (Z91.81), DISPLACED INTERTR[NAME]HANTERIC (fractures are considered one of the three types of [MEDICAL CONDITION]. The anatomic site of this type of [MEDICAL CONDITION] is the proximal or upper part of the femur or thigh bone) FRACTURE OF LEFT FEMUR, SEQUELA (a condition which is the consequence of a previous disease or injury.the long-term sequelae of infection) (S72.142S), DYSPHAGIA (Difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage.), OROPHARYNGEAL (dysphagia encompasses problems with the oral preparatory PHASE of swallowing chewing and preparing the food), (R13.12), COGNITIVE COMMUNICATION DEFICIT (disorders are problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech deficit.) (R41.841) E. On 07/19/19 at 9:53 AM, during record review of R #27's ADLs revealed no documentation of the resident's nails being cut. F. On 07/19/19 at 9:58 AM, during interview, CNA #5 revealed that the CNAs are responsible for cutting residents finger nails on their designated bath days. When asked if R #27 nails were cut on her last bath day, CNA #5 revealed that she had not cut R #27's nails. [NAME] On 07/19/19 at 10:20 AM, during an interview with ADON revealed that R #27's bath days are Tuesday and Fridays and confirmed that nail care should be done at that time. |
2020-09-01 |