Failure to Provide Adequate ADL Hygiene Before Medical Appointment
Penalty
Summary
The facility failed to follow its guideline policy for activities of daily living (ADLs) for one resident who required assistance with hygiene and routine care. On 2/10/26, the resident was sent out for a medical appointment and arrived unclean, unkempt, and unchanged for some time, as reported by the receiving RN. The Director of Nursing later stated she was informed by the resident’s family that the resident had been sent to the appointment in this unclean condition and acknowledged that staff are made aware of appointments the day prior and are expected to have residents ready on the day of the appointment. The Director of Nursing also noted that the resident had a stage three pressure ulcer on the right heel under treatment by a wound physician. The night RN assigned to the resident reported she was not aware of the appointment, stated she instructed a CNA to clean the resident while she prepared the paperwork, and was unsure whether the resident was actually cleaned before transport. This sequence of events occurred despite a facility policy stating that residents are to receive routine daily care by CNAs or RNs to promote hygiene and comfort throughout the day, evening, and night as care planned or as needed, coordinated with resident and caregiver with emphasis on resident preference. The facility’s protocol also required that a face sheet and physician order sheet be provided to the transporter when a resident is picked up, and the night RN focused on preparing this paperwork while delegating hygiene care to a CNA without confirming completion. The failure to ensure that the resident was properly cleaned and groomed prior to leaving for the appointment, in accordance with the facility’s ADL policy and with prior knowledge of the scheduled appointment, led to the resident being transported and arriving at the appointment in an unclean and unkempt state.
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