Failure to Provide Necessary Personal Hygiene and ADL Assistance
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for a resident who was unable to perform activities of daily living independently. The resident, who had diagnoses including a displaced intertrochanteric fracture of the right femur, type 2 diabetes mellitus, dementia, and anxiety, required partial to maximum assistance with oral hygiene and bathing according to the clinical record and care plan. Observations revealed the resident was unkempt, unshaven with a long beard and mustache, had matted and greasy hair, and was lying in bed with soiled sheets and a strong foul odor of urine in the room. The resident's teeth had black spots and a thick white coating, and his mouth was dry with foul breath. The resident reported not having been shaved or had a haircut in a long time and expressed a desire to be shaved. Review of CNA documentation showed missed scheduled showers on multiple dates, with no documentation that the resident received showers as planned. The facility's policy required staff to provide grooming and personal hygiene services for residents unable to perform these tasks. Interviews with staff confirmed that shaving typically occurred during showers or upon request, and that assistance was provided with oral care. However, the lack of documented and observed care indicated a failure to follow the care plan and facility policy, resulting in the resident not receiving adequate assistance with personal hygiene.