Failure to Provide Timely ADL Care and Hygiene
Penalty
Summary
The facility failed to provide activities of daily living (ADL) care in accordance with its own policy and procedures for two residents. One resident, who had moderately impaired cognition and required assistance with personal hygiene, was observed with matted hair that had not been brushed for several days. The resident reported that the last time their hair was brushed was the previous week, and only the front was brushed. Staff interviews confirmed that hair brushing should occur daily and as needed, regardless of whether the resident refused showers. Documentation did not reflect consistent refusals of care, and staff acknowledged that personal hygiene tasks such as hair brushing should still be performed even if a shower is refused. Another resident, who was incontinent and dependent on staff for toileting and hygiene, was found soiled with urine and feces in their brief. The resident communicated that they had not been changed since the previous day. Observations confirmed that the resident's brief, bed sheet, and gown were wet and soiled, and staff confirmed the resident's condition. The care plan for this resident required staff to check and change the resident at least every two hours and as needed, but this was not followed, resulting in the resident being left unclean and uncomfortable. The Director of Nursing confirmed that hair brushing is part of ADL care and should be performed after showers, during morning care, and as needed. The DON also stated that residents' briefs should be checked and changed every two hours and as needed to prevent discomfort. The facility's policy indicated that residents unable to perform ADLs independently should receive necessary services to maintain good grooming and hygiene, which was not provided in these cases.