Failure to Provide Consistent ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide consistent assistance with activities of daily living (ADLs), specifically showers or baths, for two residents who were dependent on staff for these services. One resident, admitted with diagnoses including anemia, gastroesophageal reflux disease, and anxiety, was scheduled to receive showers on specific days but did not have documentation indicating receipt or refusal of a shower or bed bath on one of the scheduled days. The Director of Nursing confirmed that the resident did not receive the required care on that date. Another resident, diagnosed with quadriplegia, neuromuscular dysfunction of the bladder, and anxiety disorder, was also dependent on staff for bathing. Documentation for this resident failed to show that showers or bed baths were provided or refused on multiple scheduled dates. The resident reported significant delays in receiving showers, citing understaffing as a contributing factor. The Director of Nursing confirmed the lack of consistent ADL assistance for this resident as well.
Plan Of Correction
1. Resident R1 has been discharged, and Resident R3 has received a shower as of 07/11/2025. 2. All residents have the potential to be affected by the alleged deficient practice. 15 residents on each unit have been interviewed regarding if they are receiving showers. 3. The Director of Nursing or Designee will in-service nursing staff on residents receiving showers at least twice weekly. The Director of Nursing or Designee will audit 10 residents' shower documentation 5 times weekly for 2 weeks and 3 times weekly for 2 weeks. 4. The Director of Nursing or Designee will report in monthly QAPI meetings the results of findings monthly for the next three months and randomly thereafter.