Failure to Provide and Document Required ADL Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to residents who were unable to perform these tasks independently. In one case, a resident who was totally dependent on staff for incontinence care was found soiled by EMTs and ER staff after being unable to obtain help for over two hours, as documented in both emergency medical records and the resident's own report. Review of the resident's medical record and ADL documentation revealed multiple shifts with no recorded incontinence care provided, and the interim DON confirmed the lack of documentation for the identified periods. Another resident, diagnosed with dementia and severe cognitive impairment, was scheduled to receive two showers per week but received only one shower per month over a four-month period, as shown by a review of the ADL documentation. Discrepancies were found between the paper shower schedules and the electronic health record, and staff confirmed that showers were not properly scheduled in the EHR. A third resident, admitted for rehabilitation and nursing care after a serious fall and hospitalization, had multiple shifts with no documentation of personal care, including hygiene, eating, dressing, and toileting. The DON and NHA were unaware of the lack of documentation and could not provide evidence that care was given during these periods.