Failure to Provide Consistent ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents who required substantial or maximal help with personal care tasks such as showering and grooming. One resident, who was cognitively intact and needed help with personal care due to reduced mobility and muscle weakness, was observed with facial stubble and food debris on his clothing. He reported not being shaved for at least three days and receiving only about one shower per week, which was an improvement from previous frequency. Documentation showed missed scheduled showers, with only four showers provided in a thirty-day period, and a ten-day span without any showers. Staff confirmed that showers and refusals are documented, but there was no formal auditing of shower completion, and the DON relied on daily dashboard reviews and informal follow-up for refusals. Another resident, who had moderate cognitive impairment and required substantial assistance with showering, was observed with soiled clothing, body odor, and unkempt hair. Documentation indicated that this resident also missed scheduled showers, receiving only five showers in thirty days. The facility's policy states that residents unable to perform ADLs should receive necessary services to maintain hygiene and grooming, but observations and records revealed that these services were not consistently provided as required.