Failure to Provide and Document Required ADL and Incontinence Care
Penalty
Summary
The facility failed to provide necessary Activities of Daily Living (ADL) care, including peri-care and incontinence care, for two residents who required extensive to total assistance. One resident, admitted with diagnoses such as immunodeficiency, end stage renal disease, dementia, and osteoarthritis, was care planned as incontinent and in need of peri-care with each episode. However, multiple days across three months showed blank documentation in the Point of Care (POC) system, indicating care may not have been provided. Grievance reports and family interviews confirmed repeated instances where the resident was found soaked in urine and not properly cleaned, with the Assistant Director of Nursing unable to explain the lack of documentation. Another resident, with severe cognitive impairment and multiple diagnoses including dementia and depression, also had significant gaps in POC documentation for peri-care across several shifts over three months. Staff interviews corroborated that the resident was found wet and that care was inconsistently documented. The Director of Nursing acknowledged that blanks in the POC were unacceptable and should have been marked as Not Applicable if care was not provided, but this was not done. These findings demonstrate a failure to consistently provide and document required ADL care for residents dependent on staff assistance.