Failure to Provide and Document Required ADL and Incontinence Care
Penalty
Summary
Facility staff failed to provide adequate care and assistance with activities of daily living (ADLs) for a resident who was dependent on staff for personal hygiene and incontinence care. The deficiency was identified when it was found that the resident was left unbathed and soiled with urine and bowel movement on multiple occasions, as reported by a complainant. Documentation review revealed that the resident was scheduled to receive showers twice weekly, but records showed only two bed baths documented for the entire month when there should have been nine entries. Additionally, there were significant gaps in the documentation of incontinence care, with long periods between recorded care events. Interviews with facility staff, including a Geriatric Nursing Assistant (GNA) and the Assistant Director of Nursing (ADON), confirmed that staff are required to document showers, refusals, and incontinence care in both electronic records and shower logbooks, and to notify nursing staff of any refusals. However, the facility was unable to provide documentation verifying that the resident received the required care as scheduled. The lack of documentation and the observations of the resident being left soiled indicate that the facility did not ensure consistent provision and recording of necessary ADL and incontinence care for the resident.