Failure to Provide and Document Required ADL Care for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide and document necessary activities of daily living (ADL) care, including toileting, incontinence care, personal hygiene, mobility assistance, turning and repositioning, and hydration, for one dependent resident during a night shift. The resident had multiple significant diagnoses, including Type 2 Diabetes Mellitus, diffuse traumatic brain injury, chronic idiopathic constipation, schizoaffective disorder (depressive type), need for assistance with personal care, flaccid hemiplegia of the left dominant side, contractures, and aphasia. An admission MDS documented severe cognitive impairment with a BIMS score of 07 and coded the resident as dependent on staff for toileting, personal hygiene, bed mobility, and as frequently incontinent of bowel and bladder. The resident’s care plan required staff to check the resident every two hours, assist with toileting as needed, observe incontinence patterns, initiate a toileting schedule if indicated, provide bedpan/bedside commode, ensure loose-fitting clothing, and provide pericare after each incontinent episode. Record review of CNA task documentation for the specified night shift showed no entries indicating that the resident received required ADL care, with multiple tasks left blank, including additional fluids, bed mobility, bowel incontinence, bowel movements, new skin observation, personal hygiene, toileting hygiene, and turning and repositioning. The assignment sheet showed one nursing supervisor, two charge nurses, and five CNAs assigned to the unit that night. A charge nurse stated the resident was total care and dependent on staff for bowel care and that CNAs are responsible for documenting care. One CNA reported the unit was short staffed with only three CNAs on the floor, stated the resident was already soaked at the beginning of the shift, and described changing the bed, providing care, and addressing a later bowel movement, but admitted she did not document the care provided. The RN supervisor stated she oversees CNA documentation and that CNAs often do not complete documentation due to short staffing, but could not recall specific events from that night. There was no documentation in the medical record that the resident refused care, and no documentation to show the resident received toileting assistance, incontinence care, turning and repositioning, or personal hygiene during that night shift as required by the care plan.
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