Failure to Provide and Document Routine Nail Care for Dependent Resident
Penalty
Summary
The facility failed to ensure that routine personal hygiene, specifically nail care, was provided to a resident who was dependent on staff for activities of daily living (ADLs). The resident had moderately impaired cognition, exhibited some physical behavioral symptoms, and was noted to be dependent on staff for bathing and required assistance for personal hygiene. The care plan specified that nail care should be performed on bath days and as needed, with staff instructed to report any changes to the nurse. Despite this, observations revealed that the resident had long fingernails with dark debris underneath, and the resident reported that nail care had not been performed for some time. Staff interviews confirmed that nail care was expected to be done during showers, but there was no documentation of nail care being offered or completed, nor of any refusals by the resident. Progress notes reviewed over a one-month period did not contain any evidence of nail care being provided or refused. Staff, including an LPN and a nursing assistant, acknowledged that nail care was not documented in the electronic medical record and that it was considered a routine practice. The DON stated that nail care would be documented only if there were continual refusals. The facility's policy required that residents unable to perform ADLs receive necessary services to maintain grooming and personal hygiene, but this was not consistently implemented or documented for the resident in question.