Health inspection·October 4, 2024

F558 Resident Rights/Exercise of Rights §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. § 72527. Patients' Rights -(a)Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 8/21/2024 at 8:50 AM, an unannounced visit was conducted at the facility to investigate a Facility Report Incident (FRI) regarding patient rights and privacy. During the investigation the Department determined that the facility failed to provide a reasonable accommodation of needs and protect the privacy of and dignity of eight of Patients 1,2,3,5,6,7,8, and 9 by failing to: 1) Ensure other male Patient s does not shower in Patient 1 and 2’s shower room (SR12) located in Room 12 (RM 12). 2) Ensure Patient 3 does not shower in RM12/SR12 without privacy. 3) Ensure other female Patient s does not shower in shower room (SR2) located inside the Patient s (Patient ’s 5, 8 and 9) room, Room 2 (R2) without privacy. 4) Ensure Patient 6 does not shower in RM2/SR2 without privacy. 5) Ensure Patient 7 does not shower in RM2/SR2 without privacy. This deficient practice had violated Patient rights for privacy and dignity for Patient ’s 1,2,3,5,6,7,8, and 9. In addition Patient 1 and 2 verbalized feeling embarrassed that could affect the patient’s psychosocial wellbeing. A review of Patient 1’s admission record indicated Patient 1 was admitted to the facility on 7/22/2024 with diagnoses that included cerebral infarction (an interruption in the flow of blood to cells in the brain) affecting right dominant side, chronic obstructive pulmonary disease (COPD- a lung disorder that prevents airflow to the lungs, causing breathing problems), cirrhosis of the liver (severe scarring of the liver), and abnormality of gait and mobility (unable to walk in a typical way). A review of Patient 1’s History and Physical Examination, dated 7/25/2024, indicated Patient 1 was alert and oriented x 3 (being alert and oriented to person, place, and time), with right sided weakness and decreased motor strength. A review of Patient 1’s Minimum Data Set (MDS, a standardized assessment and care screening tool), date 7/28/2024, indicated Patient 1 required setup or clean-up assistance (helper sets up or cleans up; Patient completes activity) with eating, partial/moderate assistance (helper does less than half the effort) with toileting, personal hygiene, and dressing, and substantial/maximal assist (helper does more than half the effort) with bathing. A review of Patient 2’s admission record indicated Patient 2 was initially admitted on 5/24/2024 and readmitted to the facility on 7/11/2024 with diagnoses that included left foot and ankle osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection), diabetes (lifelong condition that causes a person's blood sugar level to become too high), and hypertension (elevated blood pressure). A review of Patient 1’s History and Physical Examination, dated 5/26/2024, indicated Patient 2 has the capacity to make medical decisions. A review of Patient 2’s MDS, dated 7/16/2024, indicated Patient 2’s cognitive status was intact. The MDS indicated Patient 2 was independent with dressing and sit to stand, required setup or clean-up assistance (helper sets up or cleans up; Patient completes activity) with toileting hygiene, and required substantial/maximal assist (helper does more than half the effort) with shower. A review of Patient 3’s admission record indicated Patient 3 was initially admitted to the facility on 1/6/2023 and readmitted on 5/23/2023 with diagnoses that included acute embolism and thrombosis (a blood clot forms in blood vessels and partially or completely blocks blood flow and an acute embolism occurs when a blood clot or a foreign body enters the bloodstream and obstructs blood flow) of bilateral deep veins of lower extremity, cervical spinal stenosis (condition in which the spinal canal is too small for the spinal cord and nerve roots), and muscle weakness. A review of Patient 3’s History and Physical Examination, dated 7/4/2024, indicated Patient 3 had the capacity to understand and make decisions. A review of Patient 3’s MDS, dated 7/17/2024, indicated Patient 3’s cognitive status was intact. The MDS indicated Patient 3 required setup or clean-up assistance with eating, required partial/moderate assistance with toileting, shower dressing and personal hygiene. A review of facility census dated 8/21/2024, the facility census indicated Patient s 1 and 2 were roommates and roomed at RM12/SR12. During an observation on 8/21/2024 at 8:55 AM in RM12/SR12, Patient 1 was sleeping in his bed, Patient 2 was sitting at the edge of his bed with privacy curtain drawn open. During an observation on 8/21/2024 at 9:10 AM in RM12/SR12, Patient 3 came out of the shower room with certified nurse assistant (CNA) 1, draped with linen and towel and was wheeled to Patient 3’s room to be dressed. During a concurrent observation and interview on 8/21/2024 at 9:30 AM with Patient 2 in RM12/SR12, sitting at the edge of his bed with privacy curtains drawn open. Patient 2 stated, he had always seen other Patient s from other rooms take a shower in his shower room. During a concurrent observation and interview on 8/21/2024 at 9:35 AM with Patient 1 in RM12/SR12, Patient 1 was lying in bed, Patient 1 stated “I have seen other Patient s use our shower room and it sucks, it affects my privacy and dignity.” Patient 1 stated, he gets upset when other Patient s from other rooms makes so much noise when waiting to be showered. During an observation on 8/21/2024 at 9:10 AM in RM12/SR12, Patient 3 came out of the shower room with Certified Nurse Assistant (CNA) 1, Patient 3 was draped with linen and towel and was wheeled to Patient 3’s room to be dressed. During an interview on 8/21/2024 at 9:20 AM with CNA 1, CNA 1 stated, the facility only has one male shared shower room, and it is in RM12/SR12, and the room was occupied by the Patient s. CNA 1 stated, she knows there was issue with privacy and dignity of the Patient s in the room and the Patient s who are getting a shower, but that was the only shower room to be used. During a concurrent observation and interview on 8/21/2024 at 9:25 PM with Patient 3 in the room, Patient 3 was sitting on his wheelchair appropriately dressed, just finished with shower, and still had wet hair. Patient 3 stated he always showered in RM12/SR12. Patient 3 stated, he was concern about his privacy and dignity because there were other Patient s residing in the room. Patient 3 stated, sometimes on weekends in RM12/SR12 was packed with Patient s including himself, in line to be showered and on a shower, chair waiting to be showered, which makes him feel embarrassed. During an interview on 8/21/2024 at 9:40 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, RM12/SR12 was the only male shared shower room in the facility. LVN 1 stated, there was a privacy and dignity issue, the facility should have a designated shower room for the Patient s. A review of Patient 5’s admission record indicated the Patient was initially admitted to the facility on 7/15/2024 and readmitted on 7/25/2024 with diagnoses that included congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), respiratory failure (a condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide) and Dementia (a group of related symptoms associated with an ongoing decline of the brain and its abilities). A review of Patient 5’s History and Physical Examination, dated 7/25/2024, indicated Patient 5 had the capacity to understand and make decisions. A review of Patient 5’s MDS, dated 7/31/2024, indicated Patient 5’s cognitive status was intact. The MDS indicated Patient 5 required supervision with substantial/maximal assist with toileting, dressing, and roll left and right. A review of Patient 8’s admission record indicated the Patient was initially admitted to the facility on 4/20/2021 and readmitted on 6/18/2024 with diagnoses that included encephalopathy (an alteration in consciousness caused due to brain dysfunction), pulmonary edema (a condition caused by too much fluid in the lungs), and diabetes. A review of Patient 8’s History and Physical Examination, dated 6/19/2024, indicated Patient 8 does not have the capacity to understand and make decisions. A review of Patient 8’s Minimum Data Set, dated 7/26/2024, indicated Patient 8’s cognitive status was severely impaired. The MDS indicated Patient 8 was dependent (helper does all the effort) with oral hygiene, toileting, dressing, shower, and roll left and right. A review of Patient 9’s admission record indicated Patient was initially admitted to the facility on 7/30/2021 and readmitted on 2/26/2024 with diagnoses that included diabetes, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and heart failure (occurs when the heart muscle doesn't pump blood as well as it should). A review of Patient 9’s MDS, dated 5/24/2024, indicated Patient 9’s cognitive status was severely impaired. The MDS indicated Patient 9 was dependent (helper does all the effort) with toileting, shower, dressing, roll left and right, lying to sitting, and sit to stand. During an interview on 8/21/2024 at 9:50 AM, CNA 2 stated, female Patient s from other rooms were showered in room RM2/SR2 even though Patient s 5, 8 and 9 resides in RM 2. A review of facility census, dated 8/21/2024, indicated Patient s 5, 8 and 9 were roommates and resides in RM2/SR2. A concurrent observation and interview on 8/21/2024 at 9:55 AM with Patient 5 in RM2/SR2. Patient 5 was in bed with head of bed elevated receiving oxygen via nasal cannula (a small tube inserted into the nose used to deliver oxygen). Patient 5 stated, she had seen Patient s from other rooms take a shower in their bathroom. During an interview on 8/21/2024 at 10:30 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, female Patient s from other rooms were showered in room RM2/SR2. LVN 2 stated, I see the privacy and dignity issue for Patient s in room RM2/SR2, and for the other female Patient s from other rooms who gets showered in the room. A review of Patient 6’s admission record indicated the Patient was admitted to the facility on 12/28/2023 with diagnoses that included right ankle and foot acute osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection), diabetes, and hypothyroidism (happens when your thyroid gland doesn't make enough thyroid hormones to meet your body's needs). A review of Patient 6’s History and Physical Examination, dated 5/16/2024, indicated Patient 6 had the capacity to understand and make decisions. A review of Patient 6’s MDS, dated 7/3/2024, indicated Patient 6’s cognitive status was intact. The MDS indicated Patient 6 was independent with showering, personal hygiene, dressing, sit to stand and walking. During a concurrent observation and interview on 8/21/2024 at 1:20 PM with Patient 6 in Patient 6’s room, Patient 6 was awake alert sitting at the edge of the bed. Patient 6 stated, she has taken a shower in RM2/SR2, and it was not comfortable because there were other Patient s in that room, which was a privacy issue. Patient 6 stated, she feels sorry to other Patient s who goes into the room RM2/SR2 wrapped in linen and towel in the hallway and everyone could see them, and it was also a dignity issue. A review of Patient 7’s admission record indicated the Patient was admitted to the facility on 5/26/2022 and readmitted on 3/29/2024 with diagnoses that included cerebral infarction (a stroke, a brain attack, is an interruption in the flow of blood to cells in the brain), pneumonia (swelling of the tissue in one or both lungs, usually caused by a bacterial infection), and diabetes. A review of Patient 7’s History and Physical Examination, dated 7/19/2024, indicated Patient 7 had fluctuating capacity to make medical decisions. A review of Patient 7’s Minimum Data Set, dated 7/23/2024, indicated Patient 7’s cognitive status was intact. The MDS indicated Patient 7 required partial/moderate assistance with dressing, roll left and right, and substantial/maximal assist with showering. During an interview on 8/21/2024 at 11:15 AM with maintenance supervisor (MS), MS stated, he had work for the facility since 1995 and RM12/SR12 which is the current room of Patient s 1 and 2 had always been used by all male Patient s to shower, and RM2/SR2 which is the current room of Patient ‘s 5,8, and 9 had always been used by all female Patient s to shower. During an interview on 8/21/2024 at 12:15 PM with the Director of Nurses (DON) stated, RM12/SR12 was always used for the male Patient s to shower, and RM2/SR2 was always used for the female Patient s to shower. DON stated, she knows it was a privacy and dignity issue, but she thought the facility had a waiver (exemption). During a concurrent observation and interview on 8/21/2024 at 1:30 PM, Patient 7 was sitting on a wheelchair. In an interview Patient 7 stated, she goes to room RM2/SR2 for shower on a shower chair wrapped with a linen and towels. Patient 7 stated she feels “weird” going to room RM2/SR2 because of the privacy and dignity issue. A review of updated facility map dated 8/22/24, reviewed with the Director of Staff Developer (DSD), on 8/22/24 at 12PM, indicated the female Patient s takes a shower in SR2 in RM2 room that was shared by roommates Patient 5, 8, and 9. The facility map also indicated the male Patient s takes a shower RM12/SR12 located in the room of roommates Patient 1 and 2. During an interview on 8/22/2024 at 12:30 PM with the Director of Nurses (DON) stated, she acknowledged the privacy and dignity of the Patient s as a concern due to the shared shower rooms in room R2/SR2 and RM12/SR12 and she will discuss the concern with the administrator. During a review of the facility’s policy and procedure (P&P) titled “Patient Rights”, (undated), indicated; a) Patient s has the right to a dignified existence, self-determination, and must protect and promote the rights of each Patient s b) the Patient has the right to personal privacy and personal privacy includes accommodations, personal care, and c) the facility must promote care for Patients in a manner and in an environment that maintain or enhances each Patient s dignity and respect and full recognition his or her individuality. During a review of the facility’s policy and procedure (P&P) titled “Dignity, dated 2/2021 indicated; a) each Patient shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem, b) Patient are treated with dignity and respect at all times, and c) Patient ’s private space and property are respected at all times. During the investigation the Department determined that the facility failed to provide a reasonable accommodation of needs and protect the privacy of and dignity of eight of Patients 1,2,3,5,6,7,8, and 9 by failing to: 1) Ensure other male Patient s does not shower in Patient 1 and 2’s shower room (SR12) located in Room 12 (RM 12). 2) Ensure Patient 3 does not shower in RM12/SR12 without privacy. 3) Ensure other female Patient s does not shower in shower room (SR2) located inside the Patient s (Patient ’s 5, 8 and 9) room, Room 2 (R2) without privacy. 4) Ensure Patient 6 does not shower in RM2/SR2 without privacy. 5)