Failure to Implement ADL and Pressure Ulcer Care Plans
Penalty
Summary
The facility failed to implement and follow care plans for activities of daily living (ADL) and pressure ulcer prevention and management for four residents. For one resident with severe cognitive impairment and dementia, the care plan specified assistance with personal hygiene, including shaving, but observations revealed the resident was unshaven and expressed a desire to be shaved, which was confirmed by staff interviews. Another resident with Parkinson's disease, who was cognitively intact but unable to shave independently, also had a care plan indicating assistance with shaving as desired. Observations and interviews confirmed the resident had significant facial hair and had not been shaved, with no documentation of refusal. A third resident, who was cognitively intact and had hemiplegia following a cerebrovascular accident, had a care plan requiring assistance with ADLs, including nail care. Observation showed the resident's nails were long and jagged, and the responsible nurse admitted the care plan had not been implemented. The MDS nurse confirmed that the care plan was not followed for nail care. For a fourth resident with dementia and anxiety, the facility failed to implement a pressure ulcer care plan. After returning from a hospital stay where a deep tissue injury to the left heel was documented, there was no facility documentation of the wound until eight days later. Additionally, when redness to the buttocks was observed, there was no documentation or initiation of wound care orders, despite the care plan requiring observation and documentation of skin breakdown. Staff interviews confirmed the care plan was not followed for both the heel wound and the buttocks skin concern.