Failure to Maintain Resident Dignity in Hygiene Assistance
Penalty
Summary
Maple Heights Health and Rehab Center was found to be non-compliant with certain resident rights requirements as per 42 CFR Part 483, Subpart B, and the 28 PA Code. The deficiency involved a failure to maintain the dignity of a resident, identified as Resident 84, in the provision of hygiene assistance. The resident, who was capable of understanding and communicating, had a care plan indicating a need for assistance with activities of daily living, including morning and evening care. The facility's bath schedule specified that the resident was to receive showers on certain evenings, but on one occasion, the resident refused a shower and accepted a bed bath instead. Observations made on two separate days revealed that Resident 84 had visible facial hair, which had not been addressed by the staff. There was no documented evidence that the staff had asked the resident about her preference regarding facial hair removal, nor was there a policy in place for such preferences. An interview with the Director of Nursing confirmed that the staff did not have a specific protocol for addressing facial hair removal for female residents, and it was left to the discretion of the staff based on the resident's response at the time of their shower.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This Plan Of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #84 had facial hair removed at the time of the survey. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit female residents to see if they have a preference on facial hair removal and will add it to their shower day order and plan of care. To prevent a future occurrence, the Director of Nursing/designee will educate nursing staff on the resident right policy/in-service as well as the importance of following female resident's preference on facial hair removal. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit of 10 random female residents to ensure there is no facial hair present weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.