Failure to Implement Comprehensive ADL Care Plans
Penalty
Summary
The facility failed to implement a comprehensive care plan for Activities of Daily Living (ADL) for two residents, as required by their own policy and professional standards. For one resident with a self-care performance deficit due to generalized muscle weakness, observations revealed greasy hair, mild body odor, and unshaven facial hair. The resident reported missing scheduled baths, specifically stating that he had not received a bath for four days and that he was not offered one on his designated bath day. Staff confirmed the resident's unkempt appearance and acknowledged the missed care. Another resident, who required assistance with ADLs due to severe protein calorie malnutrition, polyneuropathy, chronic pain, depression, and limited range of motion, also reported not receiving a bath during the week. She stated that night shift aides no longer provided baths, which disrupted her usual bathing schedule. Both residents were cognitively intact and able to communicate their needs and preferences, but their care plans only included general interventions to assist with ADLs as needed, without specific, measurable objectives or timeframes. These deficiencies were identified through observation, interviews, and record review.