Failure to Provide and Document Required ADL Care for Dependent Residents
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 grooming and personal hygiene. For two of seven residents reviewed, documentation by certified nurse aides (CNAs) was inconsistent, with numerous omissions noted in the records for care, toileting, and dressing. One resident with diagnoses including dementia, depression, and anxiety required significant assistance with ADLs, yet CNA documentation showed 135 omissions in one month and 70 omissions the following month. The resident's family reported finding the resident soiled or wet and not dressed in their own clothing during visits. Interviews with staff confirmed that omissions in documentation indicate care was not rendered, and that all care provided or not provided should be documented with a reason. Another resident with cancer, renal insufficiency, and diabetes mellitus also required moderate to maximal assistance with personal hygiene and toileting. CNA documentation for this resident showed 35 omissions over a period of several weeks. Nursing notes documented persistent incontinence and a groin rash, and the resident's family reported having to provide incontinence care themselves, including an incident where the resident was found covered in feces. Staff interviews reiterated that all ADL care must be documented, and omissions suggest the care was not provided. The facility's policy requires that all ADL care be documented by the end of each shift, with reasons provided if care is not performed.