Failure to Provide and Document Required ADL Care and Personal Grooming
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received the necessary care and assistance to maintain good nutrition, grooming, and personal care. For two residents reviewed, documentation by certified nurse assistants (CNAs) showed multiple instances where bladder and bowel incontinence care, showers, personal hygiene, and meal assistance were either not provided or not documented as provided. Specifically, one resident with severe cognitive impairment and significant physical limitations had numerous days in January and February 2024 where required ADL care was not signed off by staff, including incontinence care, showers, personal hygiene, and meal assistance. Another resident, who was cognitively intact but required maximal assistance for mobility and was dependent for toileting and transfers, also had many occasions where incontinence care and showers were not documented as provided. Observations during facility rounds revealed that a significant number of residents were dressed in hospital gowns rather than regular clothing. On two separate days, a total of 22 and 33 residents, respectively, were observed in gowns across different floors of the facility. Interviews with staff indicated that while some residents may prefer gowns or are care planned for them, not all residents dressed in gowns had such preferences or care plans. Staff confirmed that residents had access to regular clothing and that the occurrence of residents in gowns was not typical. Interviews with facility leadership revealed inconsistencies in the interpretation of blank documentation fields. The DON stated that a blank spot in CNA documentation does not necessarily mean care was not provided, but rather that the CNA may have forgotten to sign. In contrast, the Assistant DON indicated that a blank spot would mean the task was not done. Oversight of CNA documentation was described as involving reminders and checks by nursing leadership, but the documentation reviewed for the period in question showed persistent gaps in recording required care.