Failure to Provide and Document Required Nail Care for a Resident
Penalty
Summary
A deficiency was identified when a resident was not provided with necessary care and services to maintain their ability to perform activities of daily living (ADLs), specifically in the area of grooming and personal hygiene. The resident was observed on multiple occasions with long, dirty, and untrimmed fingernails, which included brown discoloration and dirt residue. The resident expressed a desire to have her nails trimmed but reported that staff had not offered or provided this care. Facility policy required nail care to be performed to clean the nail bed and keep nails trimmed, and staff interviews confirmed that nail care should be checked and provided every shift. Review of the resident's medical record and ADL documentation revealed multiple instances where nail care tasks were either marked as 'not applicable' or lacked documentation altogether for several shifts. Staff interviews confirmed that personal hygiene, including nail care, was scheduled to be provided twice daily, and any refusals should be documented and communicated to the charge nurse. However, the care plan did not reflect any documentation of the resident's refusal to have her nails trimmed prior to a certain date, and there was no evidence that refusals were consistently addressed or care was provided as required. The Director of Nursing (DON) and other staff verified that nail care is a required component of personal hygiene and that failure to document care rendered is considered as care not being completed. The DON also confirmed that both CNAs and licensed nurses are responsible for ensuring personal hygiene tasks, including nail care, are performed and documented. The lack of documentation and observed failure to provide nail care resulted in the resident being left with untrimmed and dirty fingernails, contrary to facility policy and the resident's expressed wishes.