Failure to Provide Timely Incontinence Care and Personal Grooming for Dependent Residents
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. For one resident with severe cognitive impairment, dementia, diabetes, and a history of stroke, staff did not provide timely incontinence care as required by the resident's care plan and facility policy. Multiple observations over two days revealed persistent urine odor in and around the resident's room, wet bedsheets, and long intervals between incontinence care. Interviews with CNAs and nursing staff confirmed that the resident was not checked or changed according to the expected two-hour schedule, and staff were unaware of the lack of care until informed by surveyors. Another resident, who was cognitively intact but required maximal assistance with personal hygiene due to parkinsonism and chronic pain, was observed on several occasions with unwanted facial hair. The resident reported a preference for having facial hair removed and stated that this had not been offered recently, despite having received assistance with washing and dressing. The care plan did not indicate any refusal of care, and staff interviews confirmed that facial hair removal should be offered as part of daily ADL care but was not consistently provided. Facility policies and care plans for both residents specified the need for regular incontinence care and grooming, including facial hair removal, in accordance with individual needs and preferences. However, direct observations, resident interviews, and staff statements demonstrated that these services were not delivered as required, resulting in deficiencies in maintaining good grooming, personal, and oral hygiene for residents dependent on staff for ADLs.