Failure to Provide and Document Required ADL Care for Dependent Residents
Penalty
Summary
Facility staff failed to provide required activities of daily living (ADL) care for two residents who were dependent on staff assistance. For one resident with severe cognitive impairment and total incontinence of bowel and bladder, documentation showed multiple instances across several months where incontinence care was not provided or not documented as provided on various shifts. The resident's care plan specified the need for incontinence care to maintain dignity and prevent complications, yet ADL records were either left blank or marked as 'not applicable' on days when care should have been given. Staff interviews confirmed that such documentation was inappropriate for a resident who was always incontinent and dependent on staff. For another resident, who was cognitively intact but required set-up or clean-up assistance with oral hygiene, the facility failed to provide oral care twice daily as required. Review of the ADL tracking sheets for this resident revealed missed oral hygiene care on several consecutive days, with documentation either left blank, marked as 'not applicable,' or coded without explanation for why care was not provided. Staff interviews confirmed that the resident did not receive oral hygiene care as required during these periods. Facility policy required that ADL care, including hygiene and elimination, be documented accurately and reflect the care provided by nursing staff. The deficiencies were identified through clinical record review, staff interviews, and examination of facility documentation, which consistently failed to show evidence of required care being provided or properly documented for these dependent residents.