Failure to Provide Scheduled ADL Care for Dependent Resident
Penalty
Summary
A resident with a history of cerebral infarction and moderately impaired cognition, who was dependent on staff for activities of daily living (ADLs) such as bathing and personal hygiene, did not receive scheduled showers or shaving assistance over a period of several weeks. Documentation and interviews revealed that from mid-April to early May, there were no records of the resident receiving a shower or shave, despite being scheduled for these services twice weekly. The resident reported not having been offered a shower or shave and expressed a desire to be clean and free of odors. Observations confirmed the resident had long facial hair and a faint urine odor, and staff interviews indicated that ADL care tasks were marked as 'not applicable' in the electronic system, signifying they were not completed. Staff, including CNAs and nurses, acknowledged the resident had not received proper ADL care and could not provide reasons for the missed care. The DON and Administrator both noted the lack of documentation for showers and shaves, attributing it to possible documentation errors, but could not confirm that the care was actually provided. The facility's policy required essential ADL services to maintain grooming and hygiene, but these were not delivered as scheduled for the resident in question.