- Date
- 4/25/2024
- Report number
- OR0005010202
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to implement a service plan that reflects the resident's needs for 3 of 3 sampled residents (#'s1, 2, and 3). Findings include, but are not limited to: During an interview on 06/12/24, Staff 1 (ED) indicated the facility was cited during their survey conducted on 05/21/24 for service plans not being person centered. Staff 1 indicated s/he and Staff 2 (RCC) had been working on changing and updating all resident service plans. A review of service plans indicated the following;
• Resident 1 service plan dated 05/17/24, indicated resident was independent with showers. Staff are to provide stand by assistance with showers to help reduce falls.
• Resident 2 service plan dated 04/22/24, indicated resident was a one-person full assist twice per week.
• Resident 3 service plan dated 04/30/24, indicated resident was a two-person full assist twice per week.
A review of the shower schedule indicated the following;
• Resident 1 scheduled for showers on swing shift for Monday and Wednesdays.
• Resident 2 scheduled for showers on swing shift for Sunday and Thursdays.
• Resident 3 scheduled for showers on day shift for Wednesday and Saturdays.
A review of shower sheets from 04/01/24 through 06/05/24 provided from the facility indicated the following;
• Resident 1 had not been provided eighteen of twenty showers during the timeframe.
• Resident 2 had not been provided fifteen of eighteen showers during the timeframe. A shower sheet on 04/20/24, noted residents’ hair was matted and scalp was irritated and scabby.
• Resident 3 had not been provided five of nineteen showers during the timeframe.
It was confirmed the facility failed to implement a service plan that reflects the resident's needs.