Failure to Provide Required ADL Assistance and Documentation
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for three residents who required support due to various medical conditions. One resident with dementia, diabetes, and limited mobility was observed sitting on soiled linens with urine-soaked clothing, despite care plans indicating the need for regular incontinence care and staff checks every two hours. The Director of Nursing confirmed that all nursing staff were responsible for providing this care. Another resident with a history of cerebral infarction, hemiplegia, and vascular dementia was found to have untrimmed and dirty fingernails on multiple occasions, even though documentation on shower sheets indicated that nail care was performed. Interviews with CNAs revealed inconsistencies in nail care practices and documentation, with one CNA expressing discomfort in trimming nails and deferring the task to nursing staff, but without clear follow-up or documentation. A third resident with severe cognitive impairment, Alzheimer's disease, and a history of falls had no documented evidence of receiving showers or bed baths for two months, despite care plans and a grievance from the resident's daughter regarding the resident being wet and needing clean linen. Staff interviews indicated that showers and bed baths were to be provided and documented, but records for the relevant months were missing, and there was no confirmation that the required ADL care was delivered.