Failure to Provide Required ADL Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary Activities of Daily Living (ADL) care, including bathing, showering, oral care, grooming, and repositioning, for four dependent residents. Documentation and interviews revealed that multiple residents missed several showers, with some going up to 20 days without bathing or showering. Oral care was also frequently omitted, with one resident missing oral care on 51 shifts. In addition, required turning and repositioning for pressure wound prevention was not consistently performed, as evidenced by 42 eight-hour shifts without documentation of this care for a dependent resident. Residents affected had significant medical needs, including traumatic brain dysfunction, cerebral vascular accident, partial paralysis, and dependence on staff for all or most ADLs. One resident with a tracheostomy and contractures was not turned or repositioned as required, and another resident with dentures did not have oral care addressed in their care plan. Documentation reports and care plans confirmed these omissions, and interviews with residents and staff corroborated the lack of consistent ADL care, citing missed showers, oral care, and incontinence care. Staff interviews and grievance forms indicated that chronic understaffing contributed to the deficiencies, with reports of only three to four CNAs on certain shifts, including on units with high-acuity residents. Staff described being unable to meet basic care needs, such as incontinence care and repositioning, at the required frequency. Residents and staff reported submitting grievances and concern forms regarding missed care and staffing shortages, with some improvement only noted in the two weeks prior to the survey.
Plan Of Correction
Element 1 Resident 103 no longer resides in the facility. Resident was discharged home on 3/24/2025. Resident 104 no longer resides in the facility. Resident 104 discharged home on 3/27/2025. Resident 106 no longer resides in the facility. Resident 106 discharged to the hospital on 4/1/2025. Resident 110 continues to reside in the facility. Resident was offered a shower and ADL's including oral care was completed by 4/25/2025. Element 2A A one-time audit of the last 3 days of current residents was conducted to verify that they have received or been offered a shower/bed bath. If a shower/bed bath had not been offered at time of audit, it would be immediately offered and given or documented if refused. This was completed by the Director of Nursing/Designee by 4/25/25. A one-time audit of current residents was conducted to ensure residents received ADL care including oral care by 4/25/25. Anyone that had not received ADL care including oral care was immediately completed and documented on by 4/25/25. This was completed by the Director of Nursing/Designee. Element 3 The QAPI Committee reviewed the policy, Activities of Daily Living and deemed it appropriate by 4/25/25. The Director of Nursing has re-educated the certified nursing assistants and the licensed nurses on the Activities of Daily Living policy with emphasis to showers and ensuring residents are being offered and given showers on their shower days and completing and documenting ADL care including oral care every shift. This education will be completed by 4/25/25. Element 4 The Director of Nursing or Designee will conduct random audits weekly for four weeks and then monthly thereafter until substantial compliance is sustained, to verify that showers/bed baths and ADL care including oral care is being offered, given and/or documented if refused. Audits will be reviewed by the QAPI committee monthly for 3 months until substantial compliance is met. The Administrator is responsible to maintain compliance.