Failure to Follow Care Plans for ADL and Wound Care
Penalty
Summary
Surveyors identified that the facility failed to follow comprehensive care plans for activities of daily living (ADL) and wound care for three residents. For one resident with Alzheimer's disease, anxiety, and depression, the care plan required staff assistance with bathing and showers twice weekly. However, documentation showed that over a 30-day period, the resident received only one shower and no bed baths, despite the care plan's requirements. There were also insufficient interventions documented for instances when the resident refused showers, and progress notes only sporadically recorded refusals. Another resident, newly admitted with a right toe amputation and a lack of self-care, was observed to have poor hygiene, including greasy hair, facial hair growth, and body odor. The care plan specified showers or bed baths twice weekly, but records indicated only one shower was provided in 14 days, with no documentation of refusals. Observations and interviews confirmed the resident's unkempt appearance and dissatisfaction with the frequency of personal care provided. A third resident, who had recently undergone back surgery, was observed with a surgical dressing that had not been changed as scheduled. The care plan required daily dressing changes, but the resident reported the dressing was not changed on the previous day due to a scheduled leave for a therapy evaluation. The nurse on duty stated that the dressing change was missed because the resident left before it could be completed, and the DON confirmed that dressing changes should be completed as ordered or by the next shift. Documentation inconsistencies were noted regarding whether the dressing change was performed as required.