Failure to Provide Consistent ADL Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide required assistance with Activities of Daily Living (ADLs) for a resident who was dependent on staff for bathing, personal hygiene, and grooming. According to the resident's most recent MDS and Baseline Plan of Care, the resident required substantial to maximum support for bathing and was dependent on staff for hair care and personal hygiene, with a care plan specifying showers twice weekly. However, observations on multiple occasions found the resident in bed with unkempt hair, and the resident reported that scheduled showers were not consistently provided as planned, with shower days appearing random and hair becoming so matted that it had to be cut. Interviews with staff revealed that shower aides were sometimes reassigned to other duties, resulting in missed showers. Review of shower task sheets over an 18-day period showed only two bed baths and three documented refusals, with no additional refusals or completed showers documented for the remainder of the 30-day period. Requested documentation for the remaining days was not provided. The lack of consistent ADL assistance was confirmed by both staff and documentation review.