F0684

D

Failure to Provide Consistent ADL Care and Skin Assessment for a Resident

Terre Haute, Indiana Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately assess, prevent, and treat skin conditions and to provide consistent ADL care, including bathing and hygiene, for one resident. The resident had multiple psychiatric diagnoses, cognitive limitations, and required staff assistance with ADLs per repeated MDS assessments and care plans. Care plans identified the need for assistance with bathing, dressing, and personal hygiene, and noted delusional thinking with an intervention to postpone and re-approach care if the resident became combative or resistive. However, the medical record lacked a specific care plan and interventions addressing refusal of care, despite a discharge MDS later indicating that the resident had exhibited rejection of care 1 to 3 times during the assessment period.

Surveyors’ review of skin assessments showed multiple entries documenting no skin issues on several dates, with one assessment on 1/9/26 noting a right wrist skin issue and another on 2/4/26 noting redness under the breasts. A nursing admission assessment on 2/4/26 also documented redness under the breasts and the need for physical assistance with bathing. Shower sheets provided by the DON showed a shower on 1/16/26 and refusals on 1/20/26 and 1/23/26, but no other showers documented during that period. Point-of-care (POC) documentation indicated the resident was not provided a bath from 1/17/26 through 1/27/26, aside from the two documented refusals. The medical record lacked nursing or social services documentation of shower or bathing refusals and lacked documentation of family notification regarding such refusals.

When the resident was observed by surveyors on 2/4/26, she was alert, answered questions appropriately, and reported having had a shower the previous evening, but her hair was uncombed and disheveled and her clothing was stained with food. Interviews with CNAs revealed inconsistent accounts: one CNA stated the resident did not refuse showers if given before dark and that skin issues would be reported and documented; another CNA stated the last shower was on 1/16/26 and that the resident often would not allow staff to change her, sometimes allowing only one person to assist. A CNA who cared for the resident on the day of transfer to a behavioral center reported giving a partial bath and removing the bra, noting only some redness under the breasts, but this partial bath was not documented in the record.

At the behavioral center, an admission skin assessment documented that the resident arrived wearing a tight lace bralette that had to be cut off because it was too tight and appeared to cut into the skin under the breasts. The garment was saturated with green and yellow pus and had a foul odor, and the bilateral under-breast areas were described as excoriated, seeping yellow-green pus, and requiring cleansing and dressings. The behavioral center also documented a stage 1 deep tissue injury to a heel and a skin tear to a toe. The behavioral center’s director reported that they did not contact the originating facility about these concerns but did notify the resident’s POA. The POA later reported being told that the bra had to be cut off and that the resident had a rash under the breasts, and also stated she had not been informed by the facility of any refusal of showers or baths. The facility’s own policies on ADLs and wound management required necessary services to maintain hygiene and timely recognition and treatment of impaired skin integrity, but the documentation and interviews showed gaps in bathing provision, skin assessment prior to discharge, and care planning for refusal of care.

Additional interviews with facility staff further highlighted the lack of consistent skin assessment and documentation. An LPN who sent the resident out reported only bruising to the right arm and “a little redness” under the breasts and stated she was not aware of other skin issues. The DON stated she did not believe there was a policy to perform a skin assessment prior to discharge and that she would not normally do one, and indicated the facility relied on weekly skin checks and monthly skin sweeps. At the time of the survey interview, the DON stated the resident did not have any skin issues. The administrator stated that if a resident refused a shower, the facility would contact the family and attempt multiple times to provide bathing, but the record did not contain documentation of such contacts or repeated attempts for this resident. These combined observations, record reviews, and interviews formed the basis for the cited failure to provide appropriate treatment and care according to orders, and to adequately assess, prevent, and treat the resident’s skin conditions and daily care needs.