Failure to Provide and Document Required ADL Care and Hygiene Assistance
Penalty
Summary
Surveyors identified that multiple residents who were dependent on staff for activities of daily living (ADLs) did not consistently receive necessary care and assistance. Documentation Survey Reports and Certified Nurse Aide records for several residents, including those with diagnoses such as metabolic encephalopathy, dementia, Parkinson's disease, and muscle wasting, showed repeated omissions in recording the completion of personal hygiene, toileting hygiene, and toilet transfers across various shifts and dates. Interviews with staff confirmed that these omissions could be due to either care not being provided or a lack of documentation, with some staff unable to explain the missing records. Facility policy required that ADL care be provided based on assessed needs and that documentation be completed accordingly. One resident with moderately impaired cognition, a Foley catheter, and bowel incontinence was documented as requiring maximum assistance for ADLs and transfers. However, there was no documented evidence that personal hygiene and toileting care were provided on multiple shifts over several months. This resident also developed skin issues, including dry, fragile skin, reddened areas in the groin, and moisture-associated skin damage to the sacrum and buttocks, as noted in nursing assessments and wound consultations. Staff interviews confirmed that peri care should be completed every shift, and that lack of documentation indicated the care was not done. Another resident with severely impaired cognition and dependence on staff for personal hygiene was repeatedly observed with long, ungroomed fingernails. Both a Certified Nurse Aide and an LPN acknowledged the resident's need for assistance with grooming and that the fingernails required trimming, but neither knew when this had last been done. The facility's policy assigned responsibility for such care to the Certified Nurse Aide, and staff confirmed that the resident was not diabetic, so nail care should have been performed by aides.