Failure to Provide Required Assistance with Activities of Daily Living
Penalty
Summary
Multiple residents who were unable to perform activities of daily living did not receive the necessary care and assistance as required by their care plans and facility policies. One resident with a fractured left hand and wrist, who required substantial assistance with showering and personal hygiene, was observed with long, untrimmed facial hair and reported not receiving regular showers or shaving. Documentation confirmed missed showers on scheduled days and inconsistent recording of personal hygiene care, with staff interviews revealing that care not documented was likely not provided. Staff were unaware of refusals or missed care, and the resident did not reject care according to assessments. Another resident with limited mobility and requiring supervision for personal hygiene was repeatedly observed with unclean fingernails over several days, including during meals. Although care logs indicated that personal hygiene assistance was provided, staff admitted to not checking or cleaning the resident's nails as required. The unit manager confirmed that nail care should be performed weekly and as needed, emphasizing the importance of clean nails for hygiene and dignity, but this was not consistently done. A third resident with severe cognitive impairment and at risk for nutritional decline was not provided with the full assistance at meals as outlined in their care plan. The resident was observed unable to access their meal tray due to poor positioning and received no staff assistance during multiple meals, resulting in uneaten food and drinks. Staff interviews revealed a lack of awareness of the resident's care plan requirements, with some staff relying on personal knowledge rather than documented instructions. This led to the resident not receiving the necessary support to maintain adequate nutrition and dignity during meals.