Failure to Provide Scheduled ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and oral hygiene, for three dependent residents. For one resident with dysphagia, rheumatoid arthritis, and depression, documentation and interviews revealed that showers were not provided as scheduled in the care plan, with the resident receiving only one shower per week or less, despite being care planned for two. Staff interviews confirmed that short-staffing led to missed showers, and the resident’s POA expressed concern about inadequate hygiene care. Another resident with multiple sclerosis, diabetes with neuropathy, and major depressive disorder, who was dependent for shower transfers, reported receiving showers only once a month, contrary to the care plan specifying two showers per week. Documentation showed that showers were provided far less frequently than scheduled, and staff confirmed the resident’s care plan requirements were not met due to staffing shortages. A third resident with coronary artery disease, morbid obesity, heart failure, end stage renal disease, and diabetes, who required assistance for transfers and was at risk for pressure ulcers, did not receive regular showers or oral hygiene. Documentation indicated that showers and oral care were infrequently provided, and the resident reported long waits for peri care and a lack of assistance with oral hygiene supplies. Staff interviews confirmed that inadequate staffing and the need for two staff members for safe transfers contributed to the failure to provide scheduled care. Facility policies reviewed required daily and as-needed ADL care, including bathing and oral hygiene, but these were not consistently followed.