Failure to Develop Comprehensive ADL Care Plan for Dependent Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the functional abilities and activities of daily living (ADL) for a resident with quadriplegia, legal blindness, encephalopathy, and chronic pain. The resident was under 65 years old, severely cognitively impaired, and fully dependent on staff for all ADLs, including toileting and hygiene. Despite being always incontinent of bowel and bladder, the care plan revised in March 2025 did not include a focus or interventions for the resident's quadriplegia or ADL needs. The Kardex lacked specific information about the resident's strengths and did not document ADL, toileting, or transfer needs. Interviews with staff, including CNAs, LPNs, and the DON, revealed that the resident was known to be totally dependent on staff for ADLs and required frequent repositioning and incontinence care. However, staff were unable to locate an ADL focus in the resident's care plan, and the DON confirmed that an ADL care plan was not present in the electronic medical record. The resident's representative reported that family members often provided hygiene care, indicating a gap in staff-provided care planning and execution.