Failure to Provide Necessary Personal Hygiene Services
Penalty
Summary
During a recertification survey and complaint investigation, it was found that the facility failed to provide necessary services for two residents who were unable to carry out activities of daily living. Resident #55, who was cognitively intact and required assistance with showers, had not received a shower in four weeks. Observations revealed that the resident had unshaved facial hair, greasy and stringy hair, and debris under their fingernails. Despite being scheduled for a weekly shower, the last documented shower for Resident #55 was four weeks prior. Interviews with staff indicated that the resident required assistance with personal hygiene tasks, but these were not being completed due to staffing issues. Resident #59, who had moderately impaired cognition and required assistance with personal hygiene, had not received a shower in three weeks. The resident was observed with a full beard, long jagged fingernails with debris, and was using their hands to eat. The care plan indicated that the resident should receive nail care twice weekly and assistance with shaving on shower days. However, the last documented shower was three weeks prior, and staff interviews confirmed that personal hygiene tasks were not being completed as scheduled due to short staffing. The Director of Nursing acknowledged that activities of daily living, including showers, hair care, shaving, and nail care, should be completed according to the resident's care plan and preferences. The inability to complete these tasks was attributed to ongoing staffing issues, which were impacting the residents' self-esteem and mood. The facility's failure to provide necessary personal hygiene services was a deficiency identified during the survey.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective action for the affected residents: Personal care was provided for residents #55 and #59. This included showers, removal of facial hair/shaving, and nail trimming/cleaning. Identification of potentially affected residents: All residents are at risk of being affected by the deficiency. Personal care/grooming audits will be conducted on all residents by 4/28/25. Personal care including showers will be provided as indicated by 5/2/25. Measures to prevent reoccurrence: Education will be provided to all nursing staff. This will include the review of the following facility's policies: Hand and Nail care, Bath, Tub, Shower, and Shaving of Male and Female Resident. Emphasis will be placed on notifying the nurse in charge if care is unable to be completed for any reason. The nurse will ensure completion of care or document reasons why care was not completed (resident non-adherence). Diabetic nail care will be provided by Licensed Personnel. There will be an order for [REDACTED]. Continued compliance: Facility staff will complete auditing including personal care/grooming as well as auditing of shower compliance. Auditing will be completed on 6 residents per week for 30 days and then 12 residents per month. Results of auditing will be brought to the QA meeting. Audits will continue in place until substantial compliance has been achieved as determined by the QA Committee. DON is responsible for compliance.