Failure to Provide ADL Care and Coordinate Hospice Services for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide required activities of daily living (ADL) care, including bed baths and personal care, to a dependent hospice resident. The resident was admitted with multiple serious diagnoses, including congestive heart failure, COPD, major depression, chronic pain syndrome, multiple vertebral fractures, and generalized weakness, and the most recent MDS documented that the resident was cognitively intact but dependent on staff for all personal care. During observation, the resident was found asleep in bed with oxygen at 2.5 L/min with no date on the tubing, wearing a white T‑shirt soiled with crumbs and spilled coffee from lunch, and positioned with bare feet pressed against the hard footboard without socks or a cushion. The resident’s water glass on the overbed table was empty and undated at that time. On a subsequent observation and interview, the resident was coughing while trying to eat breakfast, and the water glass was dated from the previous day, indicating it had not been refreshed. The resident reported that hospice aides provided baths when they came in and stated he could no longer perform personal care independently. The resident was still wearing the same soiled T‑shirt from the prior day. Review of the hospice binder showed hospice CNA bath/shower visits scheduled twice weekly, with the last shower/bed bath documented on 12/30/25, indicating no bath for approximately 30 days. CNAs interviewed stated they believed hospice was responsible for the resident’s showers and that the showers listed on their task sheets corresponded to hospice visit days; they also stated they were not told to provide the scheduled showers themselves. The NHA stated that floor CNAs were expected to provide baths or showers in addition to any provided by hospice, and record review showed no documented coordination of care between the facility and the hospice agency regarding who was responsible for personal care.
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