Failure to Provide Documented ADL Care for Hospice Resident
Penalty
Summary
The facility failed to provide activities of daily living (ADL) care and assistance to a resident who was unable to perform these tasks independently. According to the facility's policy, care and services should be provided for bathing, dressing, grooming, oral care, toileting, transfer and ambulation, and eating. The resident in question was admitted with a diagnosis of liver cell carcinoma and was receiving hospice services due to increased care needs. Review of the clinical record showed documentation of care during the overnight shift, but there was no documentation of bathing or eating assistance for the resident, and the next entry was a physician note in the afternoon. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that they could not locate additional documentation to show that the resident received required ADL care and services during their stay.