| 4 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2017-03-09 |
312 |
E |
0 |
1 |
KTFZ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assist with bathing or showering for periods longer than seven days for 3 (#s 2, 3, and 20) of 24 sampled residents, and 1 (#19) of 24 sampled residents did not receive assistance with combing or brushing hair after lying down. Additionally, shower and bathing services in the Goodnow cottage lacked consistency and weekly frequency for at least 3 (#s 12, 30, 31) of 16 residents in this cottage. This deficient practice had the potential to affect all residents in the Goodnow cottage. Findings include: SHOWERS/BATHS 1. Review of resident #2's Significant Change MDS, with an ARD of 12/6/16, showed the resident's BIMS was 14, moderately intact, but she required extensive assistance with showering or bathing. Review of resident #2's Care Plan, with a start date of 1/3/17, did not address shower/bathing needs. During an interview on 3/9/17 at 9:32 a.m., resident #2 stated if she refused a shower, she would not receive another chance for a shower until the following week. The resident had to wait until the next week to receive a shower on her assigned shower day. Review of the electronic bathing reports for 12/16 - 3/8/16, showed resident #2 did not have a shower between the following dates: - 12/8/16 and 12/23/16, a span of 15 days, - 1/6/17 and 1/16/17, a span of 10 days. - 2/20/17 and 3/3/17, a span of 11 days. During an interview on 3/8/17 at 8:55 a.m., staff member V stated resident #2 went through periods of heavy sleeping and would refuse to take a shower. Staff should be offering a shower during the week. 2. Review of resident #20's Quarterly MDS, with an ARD of 2/28/17, showed the resident's BIMS at 9, moderately intact, and the resident required extensive assistance with showering or bathing. Review of resident #20's electronic bath reports, from 12/1/16 through 3/6/17, showed the resident did not have a shower between the following dates: - 12/17/16 and 1/1/16, a span of 13 days, - 1/24/17 and 2/20/17, a span of 27 days, - 2/20/17 and 3/5/17, a span of 13 days. Review of resident #20's Care Plan, with a start date of 1/3/17, did not address the resident's ADL needs including showering or bathing. During an interview on 3/8/17 at 8:55 a.m., staff member V stated resident #20 refused a shower. All the staff member could do was encourage the resident to have a shower, throughout the week. During an interview on 3/8/17 at 8:20 a.m., staff member U stated resident #20 refused showers often. The staff member stated, if she (the staff member) was available, she could usually get resident #20 to take a shower or bath for her. 3. During an interview on 3/9/17 at 9:32 a.m., resident #3 stated if she missed her shower, she was not offered another time to take one that week. She tried to take her showers on her shower day and not refuse or be unavailable. Review of resident #3's electronic bath reports, from 12/1/16 through 3/6/17, showed the resident did not have a shower between 2/9/17 and 2/23/17, a span of 14 days. Review of resident #3's Care Plan, with a start date of 2/21/17, showed the resident was to be as independent as possible with ADLs. Staff was to set up and provide assistance as needed. During an interview on 3/8/17 at 9:53 a.m., staff member V stated documentation for showers was to be documented on the Care Tracker. No other documentation was made available which showed the facility was showering or bathing the identified residents in a timely manner. HAIR CARE 4. During an observation on 3/7/17 at 5:08 p.m., resident #19 was seated at the table in the Lodge dining room. The resident's hair was flattened in the back, and on the sides of her head it was sticking up or laying in all directions. During an interview on 3/8/17 at 1:44 p.m., staff member V stated the CNAs were to comb resident #19's hair after getting her up from bed after napping. The staff member stated resident #19 had just got up from a nap. The staff member took her hand and caressed resident #19's hair down. During an observation on 3/8/17 at 4:05 p.m., resident #19 was seated in the Lodge dining room, awaiting the meal. The resident's hair did not appear to have been combed or brushed. The resident's hair was smashed to the right side of her head. Review of resident #19's Quarterly MDS, with an ARD of 1/27/17, showed the resident was cognitively impaired and required extensive assist with hygiene. Review of resident #19's Care Plan, with a start date of 2/1/17, showed staff were to encourage or assist her to eat, and she sometimes likes her plate in her lap so she can reach the food . The care plan showed the resident had a [DIAGNOSES REDACTED]. 5. Review of the Care Tracker Bath Type Detail Report for Goodnow cottage, for (MONTH) and (MONTH) of (YEAR), showed between 2/1/17 and 3/8/17, there were 16 resident showers or baths tracked in the Goodnow cottage with the following findings: Resident # 12 received one bed bath on 2/8/17. No other bathing activity was documented for the months of (MONTH) or (MONTH) of (YEAR). During an interview and observation, on 3/6/17 at 5:50 p.m., resident #12 stated she did not think she smelled bad, but the resident's hair was observed to be unclean. Resident #30 received a shower on 2/2/17, 2/23/17, and 3/2/17. The Care Tracker Bathing Type Report showed that during (MONTH) (YEAR), the resident experienced a 21 day span between showers. During an interview on 3/9/17 at 11:55 a.m., resident #30 stated she received showers on Thursdays, but she missed one recently. When she was asked about her preferred bathing frequency, she stated I prefer showers on Thursdays, every Thursday. During an interview on 3/9/17 at 12:00 p.m., resident #31 stated she preferred baths once a week, every week. She stated she was getting baths once a week. Review of the Care Tracker Bath Type Detail Report showed she was given a shower on 2/9/17 and a bath on 3/2/17, a span of 21 days between bathing events. During an interview on 3/9/17 at 10:20 a.m., staff member AA stated she was not currently aware of any residents who routinely refused baths. During an interview on 3/9/17 at 11:40 a.m., staff member H stated they had bath assignments which were by room numbers and shifts. She stated they usually gave two baths per shift. If the resident refused a bath, then the staff asked the resident two more times, and then reported to the nurse the refused bath if not given. She said they entered the occurrence of the baths in the Care Tracker electronic record. Some staff forgot to enter the baths were given. Staff member H stated they also had resident roster sheets that they carried with them when on shift. During the shift change the staff would exchange care issues and missed baths to the staff on the following shift. During an interview on 3/9/17 at 11:51 a.m., staff member C stated had no system in place for the validation of baths being given by the nursing staff to show residents were receiving their weekly or requested showers or baths. She stated the baths were missed during the evening shifts, and she would revisit the issue with the evening staff. |
2020-09-01 |