Failure to Provide Adequate ADL Care, Hygiene, and Out-of-Bed Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate activities of daily living (ADL) care, including bathing, nail care, oral hygiene, and assistance out of bed, as required by facility policy and resident needs. The facility’s ADL and oral hygiene policies required staff to assist with bathing to promote cleanliness and dignity, to provide oral care per the care plan, and to notify the DON and reschedule if showers were refused. For one resident with chronic kidney disease, major depressive disorder, anxiety, and moderately impaired cognition, there was no baseline care plan in the record. This resident was observed in the dining room with oily, stringy hair and long, jagged fingernails and reported not having received a shower that week and wanting nail trimming. Another cognitively intact resident with heart failure, hip fracture, diabetes, kidney disease, and urinary incontinence was care planned for hands-on assistance with bathing and other ADLs, but was observed in stained clothing with frizzy, messy hair and reported being supposed to receive showers twice weekly, needing assistance to shower, and desiring more frequent showers due to incontinence and odor. Shower documentation showed only three showers in January and no shower records for December. A third cognitively intact resident with muscle weakness and diabetes had no ADL care needs included in the care plan. This resident was repeatedly observed in bed with toenails on both feet approximately one-eighth of an inch long and jagged, and with a whitish-yellow substance caked on the front teeth on consecutive days. The resident reported having asked staff for help with nail trimming without receiving assistance and stated that children had to come in to help with toothbrushing because staff were too busy. A CNA stated that nail care should be provided after showers and that lack of staffing was the reason the resident was not being assisted with oral hygiene, and confirmed the resident required staff assistance with showers and personal hygiene. Staff interviews, including with an LPN and the DON, confirmed expectations that residents receive at least two showers or bed baths weekly, that hair be washed during showers, that nails be kept clean and trimmed, and that staff assist with oral hygiene. Another cognitively intact resident with heart disease, kidney disease, and high blood pressure, requiring substantial to maximum assistance for bed mobility and transfers, had no care plan completed. This resident was repeatedly observed in bed on the back, wearing a hospital gown, and reported wanting to get out of bed and wear clothing but being reluctant to ask because staff left the resident up in a chair too long. The resident stated not having gotten out of bed on one observed day, believed being too much work for staff due to needing a Hoyer lift, and expressed a desire to see outside the room. The Director of Therapy reported the resident had no restrictions, should be transferred with a Hoyer lift, and had a special high-back wheelchair in the room. A CNA stated the resident was offered to get out of bed but would refuse, and the DON stated the expectation that the resident get out of bed daily and as requested, with refusals to be reported to the nurse and documented in the record and care plan. These observations and interviews demonstrate failures to provide and document ADL care, including bathing, nail care, oral hygiene, and assistance out of bed, in accordance with resident needs and facility policy.
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