cms_SD: 1870
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1870 | AVANTARA ARROWHEAD | 435051 | 2500 ARROWHEAD DR | RAPID CITY | SD | 57702 | 2016-08-24 | 312 | E | 1 | 0 | 0LG211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and policy review, the provider failed to ensure baths were provided per policy and resident expectation for 13 of 21 sampled residents (1, 2, 3, 4, 6, 7, 8, 9, 10, 13, 15, 16, and 17). Findings include: 1. Review of the provider's 8/16/16 daily certified nursing assistant (CNA) worksheets revealed all residents were to have showers or baths twice weekly. Each resident had designated days and either AM or PM bath times written on those worksheets. 2. Interview on 8/16/16 at 2:50 p.m. with resident 9 revealed she was disappointed she only received one bath per week. She stated she was to receive two baths per week, and she had not been getting that. Interview with her on 8/17/16 at 9:10 a.m. revealed the last time she had a bath was on 8/9/16. She stated she preferred tub baths to showers, but sometimes the tub chair had been broken. At those times she would need to take a shower that she did not like. She stated she was to have had a bath early in the morning before her TED hose were put on. If those were put on before she had received a bath she knew she would not get one that day. Review of resident 9's 7/1/16 through 8/12/16 bathing records revealed she had received during the weeks of: *7/1/16: one tub bath. *7/8/16: two showers. *7/15/16: one shower. *7/22/16: no shower or tub bath. *7/29/16: one shower. *8/5/16: one tub bath. *8/12/16: one shower. For the above seven weeks she should have received fourteen showers or tub baths. She had only received five showers and two tub baths. 3. Interview on 8/18/16 at 9:25 a.m. with resident 1's daughter revealed her mother was to have received baths twice weekly. She stated she knew that was not getting done. She stated she had discussed her concern with the director of nursing and was advised they would take care of it. Review of resident 1's 7/1/16 through 8/16/16 bathing records revealed she had received a tub bath or shower twice weekly until 7/27/16. She had been hospitalized from [DATE] until 8/3/16. She received a bed bath upon her return from the hospital on [DATE]. There had been no documented bath or shower since that time. For the above seven weeks she should have received fourteen showers or tub baths. She had received six showers, one bed bath, and one tub bath. 4. Review of resident 15's 6/29/16 through 8/23/16 bathing records revealed: *She had received a bed bath on 6/29/16 and 7/1/16. *Her next bath was a tub bath on 7/16/16. *She had received a shower on 7/23/16, 8/2/16, 8/9/16, 8/16/16, and 8/19/16. For the above eight weeks she should have received sixteen showers or tub baths. She had received five showers, two bed baths, and one tub bath. 5. Review of resident 16's 6/29/16 through 8/23/16 bathing records revealed: *She had received a tub bath on 6/26/16, 7/13/16, and 7/20/16. *She had received a shower on 7/24/16, 7/27/16, and 7/31/16. *She had received another tub bath on 8/3/16. *No shower or tub bath had been documented since 8/3/16. For the above eight weeks she should have received sixteen showers or tub baths. She had received three showers and four tub baths. 6. Review of resident 17's 6/29/16 through 8/23/16 bathing records revealed: *She had received a shower on 6/26/16, 7/10/16, 7/17/16, 7/29/16, and 8/16/16. *She had received a tub bath on 7/24/16 and 8/12/16. *No shower or tub bath had been documented since 8/16/16. For the above eight weeks she should have received sixteen showers or tub baths. She had received five showers and two tub baths. 7. Review of resident 3's medical record revealed she had been admitted on [DATE] and discharged on [DATE]. Review of the CNA electronic documentation of baths completed for (MONTH) and (MONTH) (YEAR) revealed she had recieved: *7/8/16: a whirlpool bath. *7/15/16: a shower, and a resident refusal. *7/22/16: a whirlpool bath. *7/29/16: a shower. If she had received two baths per week as the facility standards stated she should have received seven baths during her stay at the facility. She had recieved two baths and two showers. 8. Review of resident 4's medical record revealed he had been admitted on [DATE]. Review of the CNA electronic documentation of baths completed for (MONTH) and (MONTH) (YEAR) revealed the weeks of: *7/1/16: There was no documentation a bath or shower had been given. *7/8/16: A partial bath was given. *7/15/16: A full bed bath was given, and a resident refusal. *7/22/16: There was no documentation of a bath or shower given. *7/29/16: A tub bath was given. *8/5/16: There was no documentation of a bath or shower given. *8/12/16: There was no documentation of a bath or shower given. Review of the 8/16/16 care plan extension CNA worksheet revealed he was to have received baths in the a.m. on Wednesdays and Sundays. If he had received two baths per week according to the facility standards he should have received fifteen baths, however he had only recieved two bed baths and one tub bath. 9. Review of resident 6's medical record revealed she had been admitted on [DATE] and discharged on [DATE]. Review of the CNA paper documentation of baths completed for (MONTH) and (MONTH) (YEAR) revealed she had a tub bath on 7/18/16. If she had received two baths per week according to the facility standards she should have received eight baths. 10. Review of resident 7's medical record revealed he had been admitted on [DATE]. Review of the CNA electronic documentation of baths completed for (MONTH) and (MONTH) revealed the weeks of: *7/1/16: There was no documentation of a bath or shower. *7/8/16: He had received a shower. *7/15/16: He had received a whirlpool bath. *7/22/16: He had received two showers. *7/29/16: He had received a shower. *8/5/16; He had received a shower. *8/12/16: He had received a shower. Review of the 8/16/16 care plan extension CNA worksheet revealed he was to receive a bath in the a.m. on Tuesdays, Thursdays, and Saturdays. If he had received three baths per week per the resident's request he should have received twenty-two baths. He had recieved six showers and one bath. Surveyor: 11. Review of resident 13's medical record revealed: *He had been admitted on [DATE]. *[DIAGNOSES REDACTED]. *He had good memory recall. *He had been admitted with multiple wounds. That had been: -Surgical wound to his left knee. -Pressure ulcers to his coccyx and right heel. *He was to have received a bath or shower twice a week on Wednesdays and Sundays. Review of the CNA electronic documentation of baths completed for (MONTH) and (MONTH) (YEAR) revealed: *He had received a shower on 8/7/16 and on 8/10/16. *According to his bathing schedule he should have received a total of nine baths during his stay in the facility. 12. Interview on 8/16/16 at 4:45 p.m. with resident 2 revealed: *She was supposed to have a bath every Tuesday, Thursday, and Saturday. *It had been well over two weeks since she had a bath. Review of resident 2's Shower Evaluation form from 7/1/16 through 8/15/16 revealed she had one form completed on 7/16/16. Review of the 8/16/16 care plan extension CNA worksheet for resident 2 revealed she should have had nineteen baths from 7/1/16 through 8/15/16. 13. Interview on 8/23/16 at 8:47 a.m. with resident 8's father revealed: *He was admitted on [DATE] and discharged on [DATE]. *He had only received two showers while he was a resident at the facility. *He had never refused to take a shower. Review of resident 8's Shower Evaluation form for 7/1/16 through 8/15/16 revealed he had one form completed on 7/18/16. Review of the provider's standard of practice revealed resident 8 should have received at a minimum eight baths. 14. Review of resident 10's Shower Evaluation form for (MONTH) (YEAR) through 8/15/16 revealed he had no forms. Review of the 8/16/16 care plan extension CNA worksheet for resident 10 revealed he should have had thirteen baths from 7/1/16 through 8/15/16. Surveyor: 15. Review of the provider's 11/17/15 Preventing, Investigating, and Reporting Alleged Sexual Assault and Abuse Violation policy revealed: *It is the policy of this center to take appropriate steps to prevent the occurrence of neglect. *Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the 8/24/16 bathing assistance needed report from the Minimum Data Set nurse revealed thirty-four residents required at least one staff person for physical assististance with bathing. Interview on 8/17/16 with CNA E revealed if she was unable to get her assigned baths completed she would document the resident had refused. She would also tell the oncoming staff and the charge nurse which baths she was unable to complete. Review of the 8/15/16 Staff Huddle notes revealed: *Today's Hot Topics: -Bathing - need to be charted in care tracker. -Need a bath sheet signed by nurse. -Review to be done on Friday. -Employees affected will receive write up. -If they have S.A. (skin assessment) by their names the nurse need to see them. Review of the provider's 1/4/16 Bath, Shower policy revealed Documentation may include: *Amount of assistance required. *Reports of unusual observations to the charge nurse. *Signature and title. Interview on 8/24/16 from 9:07 a.m. through 10:10 a.m. with the field services clinical director revealed she confirmed the provider's standard of practice was residents were to receive two baths per week or per the resident's request. | 2019-08-01 |