Failure to Assist Resident with Grooming Needs
Penalty
Summary
The facility failed to ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain grooming. Specifically, Resident 7, who has diagnoses including hypertension, anxiety disorder, and neuromuscular dysfunction of the bladder, was observed on multiple occasions with a quarter inch of facial hair over her upper lip and chin. Despite having a shower on January 27, 2025, and expressing a preference for assistance with shaving on shower days, Resident 7 did not receive the necessary grooming assistance. The facility's policy on shaving residents, last revised in 2017, requires staff to prepare for and shave residents as needed, documenting the process in the electronic health record. However, the care plan for Resident 7, which was last edited in December 2024, did not ensure that staff followed the specific ADL information. The Nursing Home Administrator was unable to provide information regarding Resident 7's facial hair and later stated that staff should offer shaving with showers and as desired. This deficiency was identified under 28 Pa. Code 211.10(d) and 28 Pa. Code 211.12(d)(1)(2)(5).
Plan Of Correction
Resident 7 has had facial hair removed. All residents have been observed and facial hair removed as needed per policy. Education provided to nursing staff, residents who are unable to carry out activities of daily living have the right to necessary services to maintain good nutrition, grooming, and personal and oral hygiene; including removal of facial hair. A QA tool has been developed to review 10% of residents weekly to ensure residents who are unable to carry out activities of daily living maintain good nutrition, grooming, and personal and oral hygiene; including removal of facial hair. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.