Failure to Ensure Consistent ADL Support and Documentation
Penalty
Summary
The facility failed to provide necessary care and services to ensure that residents did not lose the ability to perform activities of daily living (ADLs) unless medically unavoidable. For one resident with bilateral lower extremity impairment and at risk for pressure ulcers, the care plan and physician's orders required turning and repositioning every two hours. However, documentation in the Treatment Administration Record (TAR) showed multiple blanks where turning was not recorded, and there were no progress notes to indicate the care was provided. The Director of Nursing acknowledged the importance of turning for skin integrity but could not confirm the care was completed in the absence of documentation. Another resident, also with bilateral lower extremity impairment and requiring substantial assistance with showering, had a care plan intervention for staff-assisted bathing. The ADL record documentation sheet revealed several blanks for scheduled showers on the evening shift, and the resident had previously filed a grievance regarding the shower schedule. Facility policy required that refusals or provision of showers be documented, but there was no documentation to indicate whether the showers were provided or refused. These findings demonstrate a failure to ensure that residents received the necessary care and services to maintain their ADL abilities as required by facility policy and regulation.