cms_UT: 58
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 58 | MT OLYMPUS REHABILITATION CENTER | 465006 | 2200 EAST 3300 SOUTH | SALT LAKE CITY | UT | 84109 | 2019-05-23 | 677 | D | 0 | 1 | PDL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 28 sampled residents, that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, 2 residents complained of not receiving showers and the facility's documentation was unable to prove that they had been provided. Resident identifiers: 48 and 52. Findings include: 1. Resident 48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/20/19 at 1:30 PM, an interview was conducted with resident 48. Resident 48 stated she was not provided showers on a consistent basis. Resident 48 stated that on the 8th of (MONTH) she had received a shower, and was not showered again until (MONTH) 17th. Resident 48 stated prior to (MONTH) 8th she believed she had gone three and a half weeks without a shower. Resident 48 stated she had to beg for showers. On 5/21/19, resident 48's medical record was reviewed. Resident 48 had a Quarterly Minimum Data Set (MDS) assessment completed on 4/21/19. Under section G0120 titled Bathing resident 48 was coded as needing physical help in part of the bathing activity. For the amount of support provided resident 48 was coded as needing two person physical assist. Resident 48 also had a Quarterly MDS assessment completed on 1/19/19. Under section G0120, resident 48 was coded as requiring total dependence for bathing. Resident 48's care plan was reviewed and under a section titled focus the following was revealed: .The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) disease process, impaired balance, limited mobility, limited ROM (range of motion) chronic pain to lower lumbar. (At) risk for altered ADL's r/t: decline in functional ADL activity such as bed mobility .transfer .walking .dressing .toileting .and personal hygiene and bathing. The facility's record of when resident 48 received a shower or bath was requested. There was a document titled Follow up question report. This was a task which the Certified Nursing Assistants (CNA)'s filled out. The facility also provided papers which were titled shower sheets. The follow up question report and shower sheets revealed that resident 48 had received showers on the following dates: a. 2/18/19 b. 2/22/19 c. 3/5/19 (this was an 11 day gap from 2/22/19) d. 3/3/19, The shower sheets revealed resident 48 had refused a shower e. 3/30/19 (This was a 23 day gap from 3/7/19) f. 4/12/19 (This was a 13 day gap from 3/30/19) g. 4/24/19 (This was a 12 day gap from 4/12/19) h. 4/27/19 i. 5/15/19 (This was an 18 day gap from 4/27/19) j. 5/17/19 k. 5/19/19 l. 5/20/19 On 5/22/19 at 8:45 AM, an interview was conducted with CNA 6. CNA 6 stated that the CNA's know how much assistance a resident required based off of verbal reporting and the kardex. CNA 6 stated the kardex was the document which the CNA's would reference to know how to care for the residents. Resident 48's kardex was requested from the facility. Under a section titled Bathing it stated Resident prefers Tues (Tuesday), Thurs (Thursday), Sat (Saturday) PM (in the afternoon) after Dinner and PRN (as needed). On 5/22/19 at 10:10 AM, an interview was conducted with CNA 7. CNA 7 stated she had worked at the facility for one year and knew resident 48. CNA 7 stated that resident 48 required total assistance for bathing. CNA 7 stated resident 7 required a hoyer to transfer her. On 5/23/19 at 11:59 PM, an interview was conducted with CNA 5. CNA 5 stated that resident 48 required extensive assistance with showers and was totally dependent. CNA 5 stated she had worked at the facility for 2 years and worked in the section where resident 48's room was located 2 to 3 times a week. CNA 5 stated that she could recall one occasion where resident 48 had refused a shower. On 5/23/19 at 12:53 PM an interview was conducted with the Director of Nursing (DON). The DON stated that a shower sheet should be completed whether a shower was completed or refused. The DON acknowledged the gaps in resident 48's bathing and did not provide further information. 2. Resident 52 was admitted to the facility on [DATE] and readmitted after a hospital stay on 3/15/19 with [DIAGNOSES REDACTED]. On 5/20/19 at 11:00 AM, an interview was conducted with resident 52. Resident 52 stated that his scheduled shower days were Tuesdays, Thursdays, and Saturdays. Resident 52 stated that the facility does not have enough staffing to get his showers done. Resident 52's medical record was reviewed on 5/22/19. A Medicare 30 Day scheduled MDS assessment dated [DATE], documented that resident 52 required 2 person extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. A Skilled Nursing assessment dated [DATE], documented that resident 52 does not weight bear and requires assistance with bed mobility, transfers, and toilet use. In addition, resident 52 requires two person with total dependence of mechanical lift for transferring, one person with total assistance for toileting, one person with extensive assistance for bed mobility and upper body dressing, one person with total assistance for lower body dressing and footwear. A review of the CNA task charting for bathing and the Shower Sheets for resident 52 documented the following entries: (Note: It was documented that resident 52 prefers Tuesdays, Thursdays, and Saturdays for showers.) a. On Tuesday 3/5/19, received a shower. (Note: resident 52 did not receive a shower on Thursday 3/7/19.) b. On Saturday 3/9/19, received a shower. c. On Tuesday 3/12/19, received a shower. (Note: resident 52 did not receive a shower on Thursday 3/14/19 or Saturday 3/16/19.) d. On Tuesday 3/19/19, received a shower. (Note: resident 52 did not receive a shower on Thursday 3/21/19.) e. On Sunday 3/24/19, received a shower. (Note: resident 52 did not receive a shower on Tuesday 3/26/19, Thursday 3/28/19, Saturday 3/30/19, or Tuesday 4/2/19.) f. On Thursday 4/4/19, refused shower. (Note: resident 52 did not receive a shower on Saturday 4/6/19.) g. On Tuesday 4/9/19, received a shower. h. On Thursday 4/11/19, refused shower. (Note: resident 52 did not receive a shower on Saturday 4/13/19, Tuesday 4/16/19, Thursday 4/18/19, and Saturday 4/20/19.) i. On Tuesday 4/23/19, received a shower. j. On Thursday 4/25/19, received a shower. (Note: resident 52 did not receive a shower on Saturday 4/27/19.) k. On Tuesday 4/30/19, received a shower. l. On Thursday 5/2/19, refused shower. (Note: resident 52 did not receive a shower on Saturday 5/4/19.) m. On Tuesday 5/7/19, received a shower. n. On Thursday 5/9/19, received a shower. (Note: resident 52 did not receive a shower on Saturday 5/11/19.) o. On Tuesday 5/14/19, received a shower. p. On Thursday 5/16/19, refused shower. q. On Saturday 5/18/19, received a shower. r. On Tuesday 5/21/19, received a shower. On 5/22/19 at 1:14 PM, an interview was conducted with CNA 1. CNA 1 stated that she showers resident 52 on Saturdays. CNA 1 stated that she usually does not work on Tuesdays or Thursdays. CNA 1 stated that shower sheets were completed for each resident after their shower. CNA 1 stated that she was bad at completing the shower sheet forms. CNA 1 stated that showers should be charted in the CNA task section of the resident medical record. CNA 1 further stated that resident 52's charting for bathing should be correct. On 5/23/19 at 7:54 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 52 was scheduled to shower three times a week. CNA 2 stated that resident 2 was his own worst enemy because the CNAs will approach resident 52 about getting a shower and resident 52 will ask to be showered in the afternoon even though he was scheduled for the morning. CNA 2 stated that the afternoon CNAs were unable to get to resident 52 because they have scheduled showers they need to complete. CNA 2 stated that resident showers should be charted in the CNA task section of the resident medical record and a shower sheet should be completed with each shower. CNA 2 further stated that there was a shower CNA approximately four or five months and that was very helpful with getting resident showers completed timely and honoring request. On 5/23/19 at 9:00 AM, an interview was conducted with the DON. The DON stated that resident showers were assigned by rooms. The DON stated that Mondays, Wednesdays, and Fridays showers were assigned to the even number rooms and Tuesdays, Thursdays, and Saturdays showers were assigned to the odd number rooms. The DON stated that they will honor resident request if they have a preference or want to change their shower days. The DON stated that the shower days will be put in the CNA task charting in the resident medical record so the CNAs know which days to shower the resident. The DON stated that the CNAs need to complete a shower sheet for the resident even for a shower refusal. The DON stated that if a resident was scheduled for a morning shower and request to be rescheduled that day to an evening shower the CNAs were expected to give report to the CNA on the next shift and the shower should be completed. The DON stated that if the resident would like the evening shower all the time, the change needs to be made for the resident. The DON stated that the CNA task charting for bathing triggered the CNA staff to chart showers on an as needed basis everyday. The DON stated that it was recently changed in the CNA task charting to trigger on the resident's specific shower days. The DON stated that the CNAs should never chart the task as not applicable. The DON further stated that in the past they have used a shower CNA and was going to start using a shower CNA again in (MONTH) because there were issues with resident showers not being completed and incorporating the shower CNA was helpful. | 2020-09-01 |