Failure to Provide and Document Required ADL Care for Dependent Resident
Penalty
Summary
Facility staff failed to provide activities of daily living (ADL) care, specifically turning/repositioning, incontinence care, and feeding, for a dependent resident with quadriplegia, spinal stenosis, and a history of TIA. The resident was assessed as cognitively intact but fully dependent for bathing, transfer, dressing, toileting, and eating, and was always incontinent of bowel with an indwelling urinary catheter. The resident's care plan required assistance with all ADLs, including a two-person assist for bed mobility and specific catheter care interventions. A review of ADL documentation for several months revealed multiple instances where required care activities, including turning/repositioning, incontinence care, and feeding, were not documented on both day and night shifts. Interviews with staff confirmed that if care was not documented in the electronic record, there would be no evidence that the care was provided. The facility's policy required documentation of such care, but no further information or evidence was provided to show that the care was delivered on the dates in question.