Failure to Provide Safe and Dignified ADL and Incontinence Care
Penalty
Summary
The facility failed to provide personal hygiene and incontinence care in a safe and dignified manner for a resident who was unable to perform activities of daily living (ADLs) independently. The resident, who was bedbound, severely cognitively impaired, and required substantial to maximal assistance for toileting hygiene, showering, and dressing, was observed with a short beard and mustache on multiple occasions, indicating that shaving, a component of personal hygiene, was not performed as required. Staff interviews revealed confusion among CNAs regarding responsibility for shaving, with some believing it was solely the shower aide's duty. The shower aide reported not shaving the resident during a recent shower due to the resident's jerking movements but did not communicate this to other staff or the nurse, despite knowing that uncompleted ADL tasks should be reported for follow-up. Additionally, the facility failed to ensure incontinence care was provided according to accepted standards of practice. Two CNAs were observed providing incontinence care to the resident while he was suspended in a sit-to-stand lift, rather than in bed as required by facility policy and standard procedures. Both CNAs were unaware that incontinence care should not be performed while the resident was in the lift. The DON and Staff Development Coordinator confirmed that the sit-to-stand lift is intended for transfers only and that incontinence care should be performed in bed for residents unable to stand unassisted. These actions and inactions resulted in the resident not receiving proper personal hygiene and incontinence care in a safe and dignified manner.