Failure to Provide and Document Required ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care to dependent residents, as evidenced by multiple instances of missed or insufficient care. Several residents who were incontinent or required total assistance did not consistently receive timely incontinence care, bathing, or grooming. For example, one resident was observed with a soaked bedsheet and urine odor, and documentation showed that incontinent care was not recorded for all shifts on over half of the days reviewed. The DON confirmed the lack of documentation for this resident's care. Another resident, who required staff assistance for showers and had a care plan specifying two showers per week, received only three showers over a month, with missed opportunities to re-offer showers after refusals, particularly on dialysis days. In another case, a resident fully dependent on staff for eating had 15 shifts with no documentation of assistance and three shifts with only set-up, despite being unable to feed themselves. The DON acknowledged that documentation should have indicated when family provided care, but this was not consistently done. Additional deficiencies included residents with hemiplegia and high cognitive function scores who reported not receiving bed baths, changes, or showers as scheduled, despite being fully dependent on staff. Documentation sometimes indicated care was provided when residents denied receiving it, and required supporting documentation, such as shower sheets, was missing. Staff interviews revealed that care was sometimes delayed or omitted, with some staff waiting for residents to request assistance rather than proactively providing scheduled care.