Failure to Provide and Document Required ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs), specifically bathing and grooming, to two residents who were unable to complete these tasks independently. One resident, admitted with significant physical impairments including hemiplegia, muscle weakness, and a self-care deficit, was observed with several days of beard growth and reported not having received a brief change since the previous night. Documentation revealed that this resident received only one bed bath and two showers during the month, with multiple days lacking any record of bathing or grooming care. The care plan indicated the resident required staff assistance for all ADLs, but there was no documentation of refusals for most days, and staff interviews confirmed gaps in care provision and documentation. Another resident, who was cognitively intact but physically dependent on staff for bathing and toileting, also did not consistently receive scheduled showers or proper hygiene care. Documentation for this resident showed multiple days without any record of bathing or skin care, and observations revealed matted hair and prolonged periods in soiled briefs. The resident expressed embarrassment over her appearance and reported delays in receiving toileting care. Staff interviews confirmed that care was often delayed or not provided due to staffing constraints and the resident's specific preferences for how care should be delivered, with refusals not always properly documented. Throughout the review, it was noted that staff did not consistently follow facility policy regarding the assessment, provision, and documentation of ADL care. There were repeated failures to offer or document care as required, and staff acknowledged that care was sometimes delayed or omitted due to workload or resident refusals. The lack of timely and appropriate ADL care, as well as incomplete documentation, contributed to the deficiency identified by surveyors.