The findings of the complaint health survey (Intake # 24603) conducted 9/22/20 through 9/25/20 are documented in this report. The survey was conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
The sample comprised of 5 current residents. The facility had a census of 64 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cc: cubic centimeter
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
DNS: Director of Nursing Services
F: Fahrenheit
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PRN: as needed
PT: Physical Therapist
qd: every day or daily
qid: four times a day
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UTI: urinary tract infection
The findings of the health complaint revisit survey (Intake #24603) conducted on 11/13/20 are documented in this report. The facility was found to be in substantial compliance with requirements for Long Term Care Facilities, 42 CFR Part 483.
Based on interview and record review it was determined the facility failed to provide ADL assistance for dependent residents for 1 of 3 residents (#1) reviewed for bathing. This placed residents at risk for unmet needs. Findings include:
Resident 1 readmitted to the facility 4/6/20 with diagnoses including cancer and status post hernia repair.
Resident 1's 5/9/20 Quarterly MDS indicated the resident required physical assistance for bathing and the resident was cognitively intact.
The 4/2020 Shower Task Sheet indicated Resident 1 was to receive showers Sundays and Thursdays during day shift.
Review of Shower Task Sheets from 4/6/20 through 5/12/20 indicated Resident 1 did not receive showers on her/his scheduled days for 4/23/20, 5/3/20 and 5/7/20. On 4/23/20 and 5/3/20 the sheet indicated Resident 1 did not receive a shower/bath and the reason was the resident was "not available." On 5/7/20 the shower sheet indicated Resident 1 did not receive a shower/bath and the reason was listed as "not applicable." The Shower Sheet further indicated Resident 1 received bed baths instead of showers during the days reviewed.
Review of Progress Notes from 4/2020 through 5/2020 did not indicate reasons Resident 1 did not receive showers on the indicated dates nor that the resident was unavailable or out of the facility.
On 9/22/20 at 1:41 PM Resident 1 stated there were multiple occasions showers were not completed by staff after the resident returned from the hospital after 4/6/20. Resident 1 stated she/he preferred showers and during 4/2020 the resident received bed baths instead. Resident 1 further stated staff would not complete showers on her/his scheduled shower days and staff stated to the resident they would "get [her/him] next time."
On 9/23/20 at 1:58 PM Staff 6 (CNA) stated there had been issues for staff to complete showers due to scheduling, as some days one aid would have five resident showers scheduled and then another day there would be zero showers scheduled. Staff 6 further stated there was "no way" one staff member could complete five showers in one day.
On 9/23/20 at 2:15 PM Staff 7 (CNA) stated there were consistent issues for staff to complete showers for residents, including Resident 1, especially for day shift due to having more tasks during day shift, including more showers scheduled.
On 9/23/20 at 3:08 PM Staff 8 (CNA) stated at times residents did not receive showers, including Resident 1, and there were issues providing showers on the correct shower day due to the staff's utilized shower schedules not matching the Task Sheet shower schedule.
On 9/24/20 at 3:42 PM Staff 2 (DNS) acknowledged the three indicated dates Resident 1 was not bathed. Staff 2 stated the expectation was for staff to re-offer a shower if the resident was not available the first time and there was no indication the resident was re-offered a shower. Staff 2 stated she was unsure why the shower sheet was marked as "not given" and the reason being "Not Applicable" for 5/7/20 as that day was one of Resident 1's scheduled shower days. Staff 2 stated the facility was aware of issues with staff providing showers on the correct shower days for residents. Staff 2 further stated during 4/2020 the facility experienced a COVID-19 outbreak, so all residents received bed baths instead of showers to keep residents from sharing the shower room during that time.
The submission of this plan of correction does not constitute an admission by the facility of any fact or conclusion set forth in the statement of deficiencies. This plan of correction is being submitted because it is required by law.F 677 ADL CARE PROVIDED FOR DEPENDENT RESIDENTSResident #1 will be offered bathing opportunities per her preferences.DON/Designee conducted baseline audit on 10/1/20 of current residents’ bathing schedules to verify bathing opportunities are offered per their preference. Schedule was adjusted, as needed.DON/Designee initiated re-education to nursing staff 10/2/20, and ongoing, related to providing bathing opportunities per resident preference and schedule. DON/Designee will conduct audit of residents’ bathing schedules to verify bathing opportunities are offered and completed per resident’s preference and schedule. Audits will be conducted weekly for 3 weeks, then monthly for 2 months. Audit trends will be reported to facility QAPI x 3 months for review and further recommendations.
The findings of the state licensure complaint health survey (Intake # 24603) conducted 9/22/20 through 9/25/20 are documented in this report. The survey was conducted to determine compliance with OAR 411 Divisions 85 through 89. For additional information refer to the Form CMS 2567 dated 9/25/20.
The sample comprised of 5 current residents. The facility had a census of 64 residents.
Abbreviations possibly used in this document:
ADL: activities of daily living
bid: twice a day
CAA: Care Area Assessment
CBG: capillary blood glucose or
blood sugar
cc: cubic centimeter
cm: centimeter
CMA: Certified Medication Aide
CNA: Certified Nursing Assistant
DNS: Director of Nursing Services
F: Fahrenheit
HS or hs: hour of sleep
LPN: Licensed Practical Nurse
MAR: Medication Administration
Record
MDS: Minimum Data Set
mg: milligram
ml: milliliters
O2 sats: oxygen saturation in the
blood
OT: Occupational Therapist
PCP: Primary Care Physician
PRN: as needed
PT: Physical Therapist
qd: every day or daily
qid: four times a day
RA: Restorative Aide
RAI: Resident Assessment
Instrument
RD: Registered Dietician
ROM: range of motion
RN: Registered Nurse
RNCM: Registered Nurse Care
Manager
SLP: Speech Language
Pathologist
TAR: Treatment Administration
Record
tid: three times a day
UTI: urinary tract infection
The findings of the health complaint revisit survey (Intake #24603) conducted on 11/13/20 are documented in this report. The facility was found to be in substantial compliance with requirements for the OARs 411 Division 85 through 89.
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OAR 411-086-0110 Nursing Services Resident Care
Refer to F677
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