Failure to Document Resident's Required ADL Assistance in Care Plan
Penalty
Summary
The facility failed to identify and document the specific level of care assistance required for activities of daily living (ADLs) for a resident with multiple medical diagnoses, including dementia, cognitive communication disorder, muscle weakness, and diabetes mellitus. The resident's Minimum Data Set (MDS) indicated she needed partial to moderate assistance with lower body dressing, footwear, bathing, toileting, and oral hygiene, and supervision or touch assistance with upper body dressing, personal hygiene, bed mobility, and walking. The Functional Abilities Care Area Assessment (CAA) also indicated a need for staff assistance with ADLs and self-care. However, the care plan did not specify the resident's current level of functioning or the required level of assistance for bathing, transfers, dressing, oral hygiene, meals, and bed mobility. Observations showed the resident was able to walk with a walker and prepare for meals independently, and she reported no concerns about her care. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that care plans should include detailed information about each resident's level of functioning and assistance needs. The facility's policy required comprehensive assessments and individualized interventions, with care plans reviewed and updated as needed, but this was not reflected in the resident's care plan documentation.