Failure to Provide and Document Required ADL Assistance for Dependent Resident
Penalty
Summary
A resident with vascular dementia, a history of stroke, and right-sided paralysis was dependent on staff for assistance with activities of daily living (ADLs), including bathing and showering. The resident's care plan specified that two staff members were required to assist with bathing or showering three times weekly and as necessary. Documentation in the electronic medical record (EMR) and the June Bath Book showed that showers were not consistently provided according to the care plan schedule, with significant gaps in documentation for May and June. The available records indicated only a few showers were given, and there were instances of resident refusal, but overall, the required frequency of showers was not met. Interviews with the Unit Manager and DON revealed uncertainty and inconsistency regarding documentation practices for showers. The Unit Manager was unsure if CNAs were required to document showers in the EMR, and the DON confirmed that CNAs had not completed any shower sheets for the resident. No additional documentation was provided to account for the missing showers, indicating a failure to ensure that the resident received the necessary assistance with ADLs as outlined in the care plan.