Failure to Provide and Document Adequate Nail Care for Dependent Resident
Penalty
Summary
Staff failed to provide adequate nail care for a resident with severe cognitive impairment, multiple medical conditions including diabetes, and a need for assistance with personal care. Documentation indicated that nail care was provided on two occasions, but observations revealed the resident's fingernails were long and had brown matter underneath, indicating inadequate cleaning. Staff interviews revealed that the resident was resistant and sometimes combative during care, which prevented completion of nail cleaning. However, staff did not accurately document the resident's refusals or the incomplete care in the required records. Further review showed that although staff communicated verbally about the resident's resistance to nail care, this was not consistently documented in the progress notes or on the shower day skin inspection sheets. The facility lacked a formal policy for nail care, and staff relied on standard practice. The deficiency was identified through direct observation, record review, and staff interviews, which confirmed that the resident's nail care needs were not fully met and that documentation of care and refusals was incomplete.