Failure to Provide and Document Required ADL Assistance
Penalty
Summary
A deficiency occurred when a resident who required assistance with activities of daily living (ADLs), including toileting and hygiene, did not consistently receive the necessary care as outlined in their care plan. The resident, who had diagnoses including dementia, impaired mobility, and chronic kidney disease, was frequently incontinent and required maximum assistance with toileting and transfers. Multiple grievances were filed by the resident's family, citing instances where the resident was found soaked in urine and not changed by staff, as well as an incident where a certified nurse aide refused to assist the resident with toileting, resulting in distress for the resident. Documentation reviews revealed significant omissions in certified nurse aide records for bowel and bladder elimination, toilet transfers, and toilet hygiene across multiple shifts and dates. These gaps in documentation spanned both August and September, indicating a pattern of incomplete or missing records regarding the provision of essential care. Interviews with staff confirmed that documentation was not consistently reviewed or completed, with some staff citing workload and staffing shortages as barriers to proper documentation. The Director of Nursing and unit managers acknowledged the documentation issues and the lack of oversight in ensuring that ADLs were performed and recorded as required. The resident was ultimately transferred to the hospital with a diagnosis of sepsis, community-acquired pneumonia, urinary tract infection, and acute kidney injury. Family interviews and progress notes highlighted ongoing concerns about the resident's hygiene and the adequacy of care provided, including staff attitudes and responsiveness to the resident's needs. The facility's own policy required individualized assistance with ADLs, but the observed and documented failures led to the deficiency cited during the survey.