Failure to Assist Residents with ADLs, Oral Care, Communication, and Hygiene
Penalty
Summary
Three residents with significant cognitive and physical impairments did not receive necessary assistance with activities of daily living (ADLs), as observed and documented by surveyors. One resident, who had dementia, diabetes, and depression, was found to be totally dependent on staff for oral hygiene and personal care. Despite care plan instructions for daily oral care, this resident was observed with dry, scaly, and cracked lips, and staff interviews confirmed that oral care was not consistently provided. Another resident, with a history of stroke, emphysema, and failure to thrive, had a care plan indicating the need for a communication board due to a language barrier and severely impaired decision-making skills. During observation, the resident attempted to communicate needs through gestures, but the communication board was not available in the room, and staff were unable to understand the resident’s requests. Staff interviews confirmed that the communication board, which was supposed to be accessible, was not present. A third resident, admitted with sepsis, dysphagia, and muscle weakness, was also found to require substantial assistance with personal hygiene. Observations revealed that this resident’s fingernails were dirty and crusted, with black fecal matter present under the nails. Staff acknowledged the poor condition of the resident’s nails and the need for regular cleaning, as outlined in facility policy. Facility policies reviewed by surveyors emphasized the importance of grooming, infection control, and resident dignity, but these were not followed in the care of these residents.