Failure to Provide Consistent ADL Assistance and Honor Resident Preferences
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including bathing, grooming, nail care, and personal hygiene, for multiple residents who were unable to perform these tasks independently. Several residents, all with varying degrees of cognitive and physical impairment, were observed to have unmet personal care needs such as unshaven facial hair, long and unclean fingernails, and infrequent or missed showers. In one instance, a resident reported that he relied on his daughter to shave him because the facility did not have enough razors, and although he requested assistance from staff, it was not provided. Another resident stated he had only received three showers during his entire stay and that staff never offered to clip his nails, which he disliked being long and unclean. Resident Council meeting minutes and interviews revealed ongoing, unresolved concerns among residents regarding inconsistent shower schedules, lack of adherence to personal care preferences, and delayed call light responses. Residents described staff as inattentive, often preoccupied with personal cell phones or socializing with each other rather than responding to resident needs. Specific complaints included not receiving scheduled showers or bed baths, being left in soiled incontinence briefs for extended periods, and staff failing to follow up on requests for personal hygiene assistance. Documentation for ADL care, such as shower sheets, was often missing or incomplete, and there was a lack of evidence that refusals of care were properly documented or followed up by nursing staff. Facility policies reviewed indicated that residents unable to perform ADLs should receive necessary services to maintain grooming and hygiene, and that nail care should be routinely provided during ADL care. However, interviews with staff and review of records showed that these policies were not consistently followed. Residents repeatedly reported that staff cited lack of time as a reason for not providing nail care or showers, and there was no documentation of alternative arrangements or follow-up when care was missed. The facility also failed to make information about the Manager of the Day accessible to residents, limiting their ability to report unresolved issues.