Failure to Provide ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary Activities of Daily Living (ADL) care for two dependent residents. One resident, who was totally dependent due to a history of stroke, paralysis, and muscle atrophy, was repeatedly observed over several days in bed with poor hygiene, including long nails with debris, greasy and matted hair, dry lips, tacky teeth and gums, and foul breath. On one occasion, the resident was found with a strong odor of urine and bowel, and her brief, bed linens, and gown were soaked with urine and feces, indicating she had not been changed throughout the night. The resident's care plan required total assistance for all ADLs, but there was no evidence of care plan implementation or revision to address behaviors such as refusing care. Documentation indicated that ADLs had been completed, which conflicted with direct observations. Another resident, also fully dependent due to cerebral palsy, developmental disorder, and severe cognitive impairment, was observed multiple times over several days in bed with greasy, matted hair and dried drool at the corners of her mouth. Her care plan required total staff assistance for all ADLs, but there was no documentation of care plan adjustments for behaviors like care refusal. Staff interviews revealed that the resident often refused bed baths and could become combative, yet her records indicated ADLs were completed without complications, except for one documented refusal. Observations and staff comments suggested that her hair had not been brushed recently, and her hygiene needs were not consistently met. Facility policy required that all residents receive necessary care and services based on comprehensive assessments and individualized care plans, with sufficient staff to provide these services. However, the observed conditions of both residents and discrepancies between documentation and actual care provided demonstrated a failure to ensure that dependent residents received adequate ADL care as required.