Failure to Provide and Document Scheduled ADL Care for Two Residents
Penalty
Summary
The facility failed to provide necessary care and services to ensure that two residents did not experience a decline in their ability to perform activities of daily living (ADLs) without a medical reason. For one resident with diagnoses including spinal stenosis, muscle weakness, and chronic pain, documentation showed that scheduled showers or baths were not consistently provided as planned. The resident reported receiving fewer showers than scheduled, and there was no documentation to support that showers or baths were offered, refused, or that refusals were reported to nursing staff. The Director of Nursing confirmed that CNAs were not documenting the completion of showers or baths, and there was no supporting evidence in the electronic medical record for care provided. Another resident with a history of stroke, mild cognitive impairment, and mobility issues also did not receive scheduled showers or baths as planned. The resident expressed a preference for daily showers and reported not receiving even the scheduled twice-weekly showers, with no refusals documented. Record review confirmed only three showers or bed baths were provided in the last month, with no documentation explaining missed care or refusals. Staff interviews indicated a lack of knowledge about the resident's care schedule, and the Director of Nursing acknowledged that required documentation was missing.