Failure to Provide Necessary ADL Assistance and Documentation
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. One resident, with diagnoses including cellulitis, lymphedema, and benign prostatic hyperplasia, was assessed as having severely impaired cognition and was dependent on staff for bathing, dressing, and personal hygiene, and required supervision or assistance with eating. Observations revealed that staff did not consistently encourage or assist the resident to eat more when he consumed only a small portion of his meals, and there were gaps in bathing documentation, with no evidence of refusals during a nine-day period when no showers were provided. Another resident, diagnosed with multiple sclerosis, quadriplegia, and a stage 4 pressure ulcer, was completely dependent on staff for all ADLs. This resident reported not having received a bed bath in several weeks, and observations confirmed poor hygiene and an unpleasant odor in the room. The care plan indicated a preference for bed baths twice weekly, but records showed only two baths documented in a four-week period, with no consistent documentation of refusals or alternative approaches. Staff interviews confirmed a lack of awareness of refusals and inconsistent documentation practices. In both cases, the facility did not ensure that residents who were unable to carry out ADLs received the necessary services to maintain personal hygiene and good nutrition. Documentation was incomplete or missing regarding refusals and care provided, and staff did not consistently follow up or encourage residents to participate in their care as required by their care plans.