Failure to Provide and Document Required ADL and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL), specifically showers and incontinence care, to residents who were dependent on staff. One resident, who was documented as requiring staff assistance for most self-care needs, was observed multiple times with visible signs of poor hygiene, such as white flaky particles in facial hair and on clothing. Despite provider orders and a shower schedule indicating the resident was to receive showers twice weekly, records showed a significant lack of completed showers over several months, and there was no documentation of the resident refusing showers as required by facility policy. Another resident, dependent on staff for toileting, was the subject of a complaint alleging prolonged periods in soiled diapers. Review of medical records and task documentation revealed multiple shifts with no documentation of toileting or incontinence care provided. The DON confirmed that for several shifts within a 17-day period, there was no record of care being given, and the required documentation was missing. A third resident, also requiring substantial to maximal assistance for toileting, had a care plan specifying frequent checks and changes, especially after meals and at night. However, documentation for the last week of January showed four shifts with no record of incontinence care being provided. The DON reviewed staffing sheets and medical records and was unable to find documentation for the identified shifts, confirming the lack of evidence that care was provided as required.