Deficiencies in Health Care and Personal Hygiene Documentation
Penalty
Summary
The facility failed to adequately document and address changes in the health conditions of two residents, leading to a deficiency in providing appropriate health care. For one resident, multiple staff members, including a Certified Occupational Assistant and a Physical Therapy Assistant, reported changes in the resident's condition, such as not feeling well and being unable to obtain clear vital signs. Despite these reports, there was a lack of documentation of a nursing evaluation or appropriate response, such as calling 911 when the resident's condition appeared critical. The Director of Nursing acknowledged the absence of documentation and the need for a proper assessment. Another resident requested to be transferred to the hospital due to feeling unwell, but the request was not acted upon by the night shift nurse, who failed to contact a physician or document an assessment. The resident expressed dissatisfaction with the care received and was eventually transferred to the hospital the following day after a practitioner deemed the resident medically unstable. The facility's risk manager was unaware of the incident until later, and the nurse involved was suspended pending investigation. Additionally, the facility did not maintain personal hygiene for several residents, as evidenced by observations of residents with long, unkempt hair, overgrown nails, and body odor. The facility's policy required showers twice a week, but documentation showed inconsistencies in providing scheduled showers and personal care. Staff interviews revealed a lack of communication and documentation regarding residents' refusals of care, contributing to the deficiency in maintaining personal hygiene.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A. #24. grooming was completed, #69, nails were cut, #271, was shaved and showered, #72, was shaved and cut and clean, #83 was shaved, and were cut and cleaned. B. Rn staff J, CNA staff G, Unit Manager staff E, CNA staff C, CAN staff A, ADON, LPN staff W, Unit manager LPN staff M CNA staff Q and CNA staff O were all educated on F677. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: A. A Complete audit were done on all resident for proper grooming and adi care and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License staff was educated on the components of F677. B. Nursing managers will review POC documentation the following business day for any refusal and completion of ADL care and follow up as needed. C. Nursing managers will review 24-hour report for any refusal or care and follow up as needed. D. License staff was educated on documentation of care provided and refusal of care. E. Concierge rounds will include resident appearance, and any abnormal findings will be brought to morning stand up for further follow up. F. Education on F677 will be provided annually and upon new hire orientation. What systematic changes you will make to ensure that the deficient practice does not recur: A. License nurses was educated on resident request to be sent to the hospital and documentation of change in condition. B. Nursing managers will review 24 hour report the following morning for any documentation of change in condition to ensure appropriate interventions were taken including but not limited to sending the resident out to the hospital. C. is to bring all concerns of change in condition to the morning meeting for re follow up by the nurse management team. D. License nurses will document and assess any concerns brought to them by any staff members regarding a change in condition and they must notify physician in a timely manner to obtain further interventions and if nurses are unable to get ahold of the physician they can contact the medical director. If in an emergent case such as distress, or license nurses will call 911 and have resident sent to the hospital and then document entirely on the findings and interventions. E. Staff will use the interact stop and watch program/ form to relay any change in condition noted by any resident at the facility. A copy of the stop and watch form will also be brought to morning clinical meeting to be reviewed by nurse managers/IDT to ensure appropriate measures were taken and followed. F. Staff education on the components of F684 this education will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing /Designee will audit the follow up for any change of condition or request to go to the hospital to ensure timely assessment, documentation and notification is obtained and audit communication for change in condition weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.