Failure to Provide Required ADL Assistance and Showers
Penalty
Summary
Three residents did not receive necessary assistance with activities of daily living (ADLs) as required by facility policy. One resident, who had severe cognitive impairment, Alzheimer's disease, and was on Hospice care, was observed multiple times in bed in an uncomfortable position, not having been repositioned or checked for incontinence for several hours after the start of the morning shift. The resident's breakfast tray was not set up or assisted with, despite care plan interventions requiring frequent checks and assistance with eating due to a history of aspiration and swallowing issues. Staff interviews confirmed that the resident had not been repositioned, checked, or assisted with eating until late in the morning, and the resident was found incontinent and in need of assistance at that time. Another resident, who was cognitively intact but required substantial assistance with showering and dressing, reported not receiving weekly showers and expressed a desire for more frequent showers. The resident had filed a grievance requesting two showers per week, but the care plan, Kardex, and shower schedule were not updated to reflect this request. Review of documentation showed only six showers were recorded over several months, and staff confirmed that the resident's request and grievance were not properly addressed or implemented in the care planning process. A third resident, with moderately impaired cognition and significant physical limitations including an above-knee amputation, reported not being offered a shower since admission two weeks prior. The resident's care plan and MDS assessment contained conflicting information regarding the level of assistance needed for bathing. No shower sheets, refusal documentation, or skin checks were found for this resident, and staff confirmed that the resident had not received a shower or the required skin assessments since admission. The facility's policies required at least weekly showers and proper documentation, which was not followed in these cases.