Failure to Provide Consistent ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically showering and personal hygiene, for four residents who required varying levels of staff support. Observations over several days revealed that these residents consistently had greasy hair, indicating a lack of proper hygiene care. Documentation in the electronic medical record showed that showers were not provided according to the residents' stated preferences, with some residents receiving fewer showers than scheduled and others having missed or refused showers without evidence of appropriate follow-up or re-approach by staff. Interviews with staff confirmed that shower aides were frequently reassigned to other duties, which contributed to missed showers, and that if care was not documented, it was likely not performed. The residents involved had different cognitive and physical abilities, ranging from cognitively intact but physically dependent to severely cognitively impaired and fully dependent on staff for showers. Despite facility policy requiring assistance with ADLs as needed, the lack of consistent showering and hygiene support was evident through both staff interviews and resident reports. One resident reported being denied a shower due to staff being busy, and another was found to have received only two showers in a 30-day period. The facility's documentation practices and staff allocation contributed to the failure to meet residents' ADL needs.