Failure to Provide Consistent ADL and Incontinence Care
Penalty
Summary
The facility failed to consistently provide necessary care and services to residents dependent on staff for activities of daily living (ADLs), specifically in the areas of personal hygiene and incontinence care. One resident with Parkinson's Disease and muscle weakness, who was cognitively intact and required substantial assistance for bathing, reported that scheduled showers were frequently missed, sometimes for up to three weeks. Documentation confirmed multiple instances where showers were not provided or not documented as completed, with no supporting evidence of a medical reason for omission. The facility's records and staff interviews corroborated these inconsistencies, and the Nursing Home Administrator was unable to explain the lapses in care or documentation. Another resident with paralytic syndrome, hydrocephalus, and muscle weakness, who was always incontinent of urine and bowel, was care planned to receive regular toileting assistance and incontinence checks. However, the resident reported extended periods in soiled briefs, including an incident where requests for a change after dinner were not addressed until the following morning. Review of electronic care records showed gaps and inconsistencies in documentation of incontinence care, with missing entries and lack of evidence that the resident's individualized needs were met as outlined in the care plan. The Director of Nursing confirmed that the resident should have been on a two-hour check and change program, but the facility could not provide documentation to support that this was consistently implemented. These findings were based on clinical record reviews, resident and staff interviews, and facility documentation, demonstrating that the facility did not ensure residents dependent on staff for ADLs consistently received the necessary care and services to maintain personal hygiene and dignity.