cms_WY: 5
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5 | GRANITE REHABILITATION AND WELLNESS | 535013 | 3128 BOXELDER DRIVE | CHEYENNE | WY | 82001 | 2019-04-11 | 677 | E | 1 | 1 | TYBQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review and resident and staff interview, the facility failed to provide services to maintain personal and/or oral hygiene to 15 of 37 sample residents (#5, #11, #24, #50, #51, #54, #67, #75, #80, #88, #91, #103, #108, #109, #112), reviewed. The findings were: 1. Review of the 2019 (MONTH) and (MONTH) Resident Functional Performance bathing documentation for resident #5 showed the resident received a shower on 3/7, and did not receive another shower until s/he received a bed bath on 4/3 (28 days). There was documentation the resident refused showers on 3/19 and 3/26. 2. Review of the 1/8/19 quarterly MDS assessment showed resident #11 had a BIMS score of 8/15 (moderately impaired cognition) and required the extensive assist of 1 for personal hygiene and bathing. The following concerns were identified: a. Observation on 4/8/19 at 4:46 PM showed the resident's teeth were coated with a white substance. Interview with the resident at that time revealed s/he did not brush his/her teeth. b. Review of the care plan revised on 7/23/18 showed the resident was at risk for dental health problems and interventions included monitor/document report PRN any s/sx of oral/dental problems needing attention. Further review of the care plan showed the resident required assistance with bathing/showering. c. Review of the (MONTH) 2019 Functional Performance Record showed the resident went from 3/2 to 3/13 without a bath or shower (11 days). Further review showed the resident went from 3/1 to 3/21 without oral care (20 days). d. Interview on 4/11/19 at 11:31 AM with the DON revealed she had educated staff about baths and resident refusals and confirmed the baths were not clearly documented. She further stated staff were educated on oral care and was not sure why residents were not receiving it. 3. Review of the 2/1/19 annual MDS assessment showed resident #24 had moderate cognitive impairment; required supervision with ambulation; required extensive assistance with dressing and was totally dependent on staff for bathing and showering. Review of the care plan, revised 12/27/18, showed s/he was at risk for ADL self-care performance deficit due to dementia, change in cognitive status, vision problems and incontinence. Review of the shower schedule showed the resident was scheduled to receive 2 showers/baths weekly. Review of the 3/1/19 to 4/8/19 Resident Functional Performance Record showed the resident did not receive a bath or shower from 3/9/19 to 3/16/19 (7 days). Further review showed no documented refusals. 4. Review of the 2/19/19 quarterly MDS assessment showed resident #50 required the physical assistance of one staff member for bathing. Review of the (MONTH) 2019 Resident Functional Performance bathing documentation showed the resident had a shower on 3/19 and did not receive another until 3/29 (10 days). Further review showed no evidence the resident had refused a shower during that timeframe. 5. Review of the 2/19/19 quarterly MDS assessment showed resident #51 had severe cognitive impairment and required extensive assistance with bathing and personal hygiene care. Review of the care plan, revised 12/28/18, showed the resident had ADL self-care performance deficit due to dementia; and staff were directed to provide a sponge bath when the resident could not tolerate a full bath or shower. Review of the shower schedule showed the resident was scheduled to receive 2 showers/baths weekly. Review of the 3/1/19 to 4/8/19 Resident Functional Performance Record showed the resident did not receive a sponge bath or shower from 3/7/19 to 3/15/19 (8 days). Further review showed no documented refusals. 6. Review of the 2019 (MONTH) and (MONTH) Resident Functional Performance bathing documentation for resident # 54 showed the resident had a shower on 3/1 and did not receive another until 3/12 (11 days); a shower on 3/18 and did not receive another until 3/24 (6 days); and from 3/24 the resident did not receive a shower again until 4/11 (18 days). 7. Review of the 3/13/19 admission MDS assessment showed resident #67 was admitted to the facility on [DATE]; had a BIMS score of 15/15 (cognitively intact); and required the total assistance of two staff members for bed mobility and transfers, and the extensive assistance of one staff member for personal hygiene. The following concerns were identified: a. Interview on 4/8/19 at 11:30 AM with the resident revealed s/he was using mouthwash for oral care because no one had offered to assist him/her with brushing his/her teeth. In addition the resident stated s/he had not brushed his/her teeth since admission and my mouth feels horrible and my breath stinks. b. Review of the ADL care plan, initiated on 3/17/19, showed the resident required assistance with grooming/hygiene. c. Review of the dental care plan, initiated on 3/17/19, showed the resident was at risk for potential dental issues related to decreased/limited mobility. The resident was to remain free of infection, pain or bleeding in the oral cavity by review date. However, there were no interventions regarding routine oral care. d. Review of the CNA's Care Directive Form showed the resident had his/her own teeth and required extensive assistance with grooming. In addition, the CNAs were to encourage independence with upper body ADLs. e. Interview on 4/10/19 at 9:22 AM with the DON revealed she expected oral care to be offered after each meal and the resident assisted as needed. 8. Random observation of resident care on 4/7/19 at 7:32 PM showed CNA #6 transferred resident #75 to bed without providing oral care and left the room. Interview with the CNA at that time revealed the resident was in bed for the night. 9. Review of the 2019 (MONTH) Resident Functional Performance bathing documentation for resident #80 showed the resident went without a shower from admission on 3/8/19 until discharge on [DATE] (20 days). 10. Review of the 2/28/19 admission MDS assessment showed resident #88 required the physical assistance of one staff member for bathing. Review of the (MONTH) 2019 Resident Functional Performance bathing documentation showed the resident had a shower on 3/16 and did not receive another until 3/26 (10 days). Further review showed no evidence the resident had refused a shower during that timeframe. 11. Review of the 2/19/19 admission MDS assessment showed resident #91 required the physical assistance of one staff member for bathing. Review of the (MONTH) 2019 Resident Functional Performance bathing documentation showed the resident had a shower on 3/10 and did not receive another until 3/25 (15 days). Further review showed no evidence the resident had refused a shower during that timeframe. 12. Review of the 2019 February, March, and (MONTH) Resident Functional Performance bathing documentation for resident #103 showed the resident had a shower on 2/15 and did not receive another until 3/5 (17 days); received a shower on 3/7 and did not receive another until 3/18 (11 days). Interview with resident #103 on 4/7/19 at 5:12 PM revealed s/he was supposed to have received a shower that day, but did not. S/he stated the hot water must have went out. 13. Review of the 3/8/19 admission MDS assessment for resident #108 showed the resident was admitted on [DATE] and did not receive a bath during the 7-day look-back period. Review of the (MONTH) 2019 Resident Functional Performance bathing documentation for the resident showed the resident had a shower on 3/10 and did not receive another until 3/25 (15 days). Further review showed no evidence the resident had refused a shower during that timeframe. 14. Review of the (MONTH) 2019 Resident Functional Performance bathing documentation for resident #109 showed the resident had a shower on 3/1 and did not receive another until 3/9 (8 days). Further review showed the resident's next shower was on 3/26 (17 days). There was no evidence the resident had refused a shower during the gaps between shower days. 15. Review of the 2019 (MONTH) and (MONTH) Resident Functional Performance bathing documentation for resident #112 showed the resident had a shower on 3/1 and did not receive another until 3/17 (16 days); and received a shower on 4/1 and did not receive another until 4/8 (7 days). 16. Interview on 4/10/19 at 12:41 PM with CNA #7 revealed she was the bath aide for the first floor. In addition, during the timeframe in (MONTH) when the showers were not being completed she had been pulled to work in other areas of the building and no one had showered the residents in her absence. 17. Interview with the DON on 4/10/19 at 3:25 PM revealed the facility's expectation was for staff to offer residents a shower or bed bath twice a week and document it. If a resident refused 3 times the staff were to notify the nurse. 18. Interview on 4/11/19 at 11:13 AM with the DON revealed she was aware of the gaps between showers and had implemented new shower schedules. | 2020-09-01 |