Failure to Provide Required ADL Assistance for Feeding and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents. One resident with diagnoses of cerebrovascular disease and Alzheimer's disease, and a Brief Interview for Mental Status score of 0/15 indicating impaired cognition, was observed multiple times with food on their clothing protector and face, attempting to eat with their fingers, and without staff present to provide the ordered 1:1 feeding assistance. The resident's medical record included an active physician's order for 1:1 feeding assistance, and both staff and the registered dietitian confirmed the resident required significant help with meals, especially when eating in their room. Another resident, recently admitted with hypertensive heart disease and a mood disorder, was observed to have facial stubble for several days and reported a preference to remain clean shaven but was unable to shave independently. The resident stated that staff had assisted with shaving, but not frequently. Staff interviews revealed that shaving was only provided on shower days, twice a week, and the DON confirmed that the facility protocol did not specifically assess or address resident preferences for shaving frequency in the care plan. Facility policy required that residents unable to perform ADLs receive necessary services for grooming and hygiene, but this was not consistently implemented.