Failure to Provide Consistent ADL Assistance and Nutrition Support
Penalty
Summary
The facility failed to provide consistent assistance with activities of daily living (ADLs) for two residents who were dependent on staff support. One resident, admitted with a history of cerebral infarction and type 2 diabetes with neuropathy, required moderate staff assistance for showering and was cognitively intact. Despite a physician's order for scheduled showers twice weekly, documentation showed the resident missed several scheduled showers and received bed baths instead, without any record of refusal or preference for bed baths. The facility did not provide evidence that showers were given as planned. Another resident, admitted with diffuse large B-cell lymphoma and dysphagia, was severely cognitively impaired and required supervision for eating. Observations revealed that after staff set up the resident's lunch tray, they left the resident unattended for 25 minutes, during which the resident did not attempt to eat and instead placed a blanket in his mouth. The care plan did not accurately reflect the resident's current functional ability or the level of staff assistance required for eating and other ADLs. Occupational therapy documented a significant decline in the resident's self-feeding ability, indicating total dependence, but this information was not communicated or updated in the care plan, physician orders, or CNA huddle binder. Interviews with facility staff confirmed that the necessary information regarding the resident's decline and required assistance was not effectively communicated to the interdisciplinary team or primary caregivers. As a result, staff were not aware of the resident's need for total assistance with feeding, and the facility failed to provide the necessary services to maintain good nutrition and personal hygiene for the residents involved.