Based on interview and record review, conducted during a site visit on 03/19/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (#1). Findings include, but not limited to:
During an interview on 03/19/24, Staff 1 (ED) stated showers were documented on the shower sheets and the RCC reviewed the shower sheets weekly. S/He stated the resident would sign the shower sheets if they refused. Staff 1 stated housekeeping was done weekly and documented by the housekeepers.
During an interview on 03/19/24, Resident 1 stated s/he was supposed to get standby assist for showers on Wednesday and Saturday mornings, but they had not been coming. S/He stated staff would come in at 9 pm and s/he would decline because it was too late. S/He also stated that s/he didn't get a shower for a month straight. Resident 1 stated they had a really good housekeeper, however, s/he only cames every other week.
Review of Resident 1's service plan dated 02/19/24 indicated the resident required standby assistance with bathing twice weekly. There weren't any completed shower sheets for December 2023 and only one progress note dated 12/13/23 at 11 am which stated, "Asked resident if [s/he] would like to get ready for [his/her] shower per resident [s/he] received [his/hers] yesterday in the daytime".
Review of December 2023 housekeeping logs indicated Resident 1 was getting weekly housekeeping done.
The findings were reviewed with and acknowledged by Staff 1 on 03/19/24.
It was confirmed the facility failed to ensure the implementation of services.
Verbal POC: Facility will start weekly audits of the shower sheets by the RCC's and they will turn them into the nurse for review to ensure that residents are getting their showers and they are being documented.
Based on interview and record review, conducted during a site visit on 03/19/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#3). Findings include, but not limited to:
A review of Resident 3's November 2023 MAR, progress notes, and physician orders indicated the following:
·Order for Setraline 25 mg tab (Zoloft) to be given 0.5 tablet (12.5 mg) by mouth every day for depressive episodes.
·November 2023 MAR revealed that between 11/26/23-11/30/23 resident did not get their medication due to it being out of stock and waiting on delivery from pharmacy.
During an interview, Staff 1 (ED) and Staff 2 (Wellness Director) stated the incident had occurred.
The findings were reviewed with and acknowledged by Staff 1 on 03/19/24.
It was confirmed the facility failed to carry out medication and treatment orders as prescribed.
Verbal plan of correction: MT meeting last month on 2/14/24 to review policy and procedures for ordering/re-ordering medications and documentation.