Failure to Provide and Document Required Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who required assistance with activities of daily living (ADLs) did not receive adequate nail care. Multiple observations over several days showed the resident lying in bed with untrimmed fingernails and dark debris underneath them. The resident reported that staff did not clean her nails very often. Review of the resident's care plan indicated a need for assistance with ADLs, including nail care on bath days and as necessary. The resident's diagnoses included multiple sclerosis, and the Minimum Data Set (MDS) assessment documented moderate cognitive impairment and dependence for ADLs. Documentation review revealed inconsistencies in recording nail care, with some shower sheets lacking evidence that nail care was provided or refused, and no progress notes indicating refusal. Facility policy required daily cleaning and regular trimming of nails, with documentation of care provided. An LPN confirmed that nail care should have been performed with each bath and as needed, but this was not consistently done or documented for the resident.