Resident Left in Soiled Condition Due to Inadequate Hygiene Care and Documentation
Penalty
Summary
A deficiency occurred when a male resident with multiple complex medical conditions, including advanced cancer, malnutrition, dysphagia, and cognitive communication deficits, was left for an extended period covered in a substance that appeared to be dried vomit and other detritus. The resident required substantial to maximal assistance with self-care activities, as documented in his Minimum Data Set (MDS). On the day in question, the resident experienced episodes of vomiting, which were documented by nursing staff, and was administered medication for nausea. However, photographic evidence provided by a complainant showed the resident lying in bed shirtless, with dried brown substances visible on his chest, stomach, chin, facial hair, and hands, as well as a vomit bag with a significant amount of brown substance next to him. Interviews with staff revealed inconsistencies in the provision and documentation of personal hygiene care. The Certified Nursing Assistant (CNA) assigned to the resident stated she entered the resident's room multiple times to clean vomit but did not document each instance, citing a lack of a place to chart. The Activities of Daily Living (ADL) log only reflected two instances of personal hygiene care for the resident on the day in question. Other staff members, including the Director of Nursing (DON) and another CNA, stated that if a resident was observed to be dirty or covered in vomit, they would expect immediate cleaning. The DON acknowledged there was no way to determine how long the resident was left in this condition and estimated it would take 1-2 hours for vomit to dry. The facility's documentation and policy review indicated that all care actions, including hygiene assistance, should be recorded each time they are performed. However, the Administrator confirmed that charting was done by exception and could not specify an acceptable timeframe for how long a resident could remain soiled before being cleaned. The facility was unable to provide a copy of its Resident Rights policy during the survey. The failure to ensure timely and adequate hygiene care for the resident, as well as proper documentation, resulted in the resident remaining in a soiled and undignified state for an extended period, as evidenced by both photographic documentation and interviews.