Failure to Develop and Implement Hygiene Care Plan for Dependent Resident
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a care plan addressing hygiene care, specifically hair and nail care, for a resident with significant medical needs. The resident, a male with quadriplegia, Parkinson's disease, myocardial infarction, malnutrition, heart failure, chronic kidney disease stage 3, gastrostomy status, dysphagia, and a history of nontraumatic intracerebral hemorrhage, was admitted to the facility and was dependent on staff for activities of daily living. Despite a physician's note documenting family concerns about the resident's dry, flaky scalp and a subsequent order for medicated shampoo to address tinea versicolor, there was no evidence in the care plan of goals or interventions related to hair and nail care for this dependent resident. Observations confirmed the presence of yellow flakes on the resident's oily scalp and uncut nails, indicating that hygiene needs were not being met. The findings were corroborated by the facility's director of nursing and wound care nurse. Review of the facility's care plan policy showed that care plans are intended to address identified problem areas to maintain the highest level of resident functioning, but in this case, the care plan did not include necessary interventions for the resident's hygiene care.