Failure to Provide Adequate ADL Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a dependent resident, specifically in the area of hair care. The resident, who had hemiplegia and hemiparesis following a cerebral infarction and required assistance with personal care and had reduced mobility, was observed on multiple occasions with greasy and unkempt hair. Documentation showed that showers or bed baths were scheduled and recorded on certain days, but there were gaps in documentation and no record of refusals or incomplete care. The resident reported that her hair was not being washed as frequently as she preferred, and staff interviews confirmed that hair washing was expected to be part of shower or bed bath routines, but it was not always performed or documented. Observations over several days revealed the resident wearing the same clothing and with consistently greasy hair, despite scheduled care. Staff interviews indicated confusion or lack of clarity regarding whether hair washing had been completed, and there was no separate documentation for shampooing in the CNA records. The care plan indicated a preference for bed baths, but there was no evidence that hair care was consistently provided as part of this routine. The lack of documentation and inconsistent care led to the resident's unkempt appearance and unmet personal hygiene needs.