Failure to Provide and Document ADL Care for Dependent Residents
Penalty
Summary
Facility staff failed to provide and document activities of daily living (ADL) care for four residents who were unable to perform these tasks independently. For one resident, records showed significant gaps in bathing and showering documentation over several months, with only a small fraction of opportunities for care being recorded and most entries left blank. When additional documentation was requested, only two shower sheets were produced for a three-month period, despite policy requiring regular review and documentation of bathing preferences and frequency. Another resident, assessed as severely impaired in decision-making and requiring substantial assistance with personal hygiene, was repeatedly observed with untrimmed facial hair over several days. The care plan indicated the need for daily grooming and assistance, and staff interviews confirmed that grooming, including shaving, should be performed daily or as needed. However, there was no documentation of care refusals or attempts to address the facial hair, and ADL records showed minimal entries for personal hygiene during the review period. A third resident, also severely impaired and requiring supervision for toileting, had multiple dates across three months where there was no evidence of toileting assistance being provided or documented on various shifts. The care plan specified the need for staff assistance with toileting, but ADL records showed numerous blank entries. For a fourth resident, who was totally dependent on staff for personal hygiene due to quadriplegia, there was no documentation of personal hygiene care or refusal on a specific date, despite the care plan requiring daily assistance. Staff interviews confirmed that care should be provided and refusals documented, but the absence of records made it impossible to determine if care was given.