Failure to Provide and Document ADL Bathing and Incontinence Care
Penalty
Summary
The facility failed to provide adequate ADL care, including bathing and incontinence care, to residents who were dependent on staff. One resident with diabetes, end-stage kidney disease requiring dialysis, and gait and mobility abnormalities requiring assistance with ADLs was observed disheveled, with greasy hair, body odor, disheveled bedding, wearing only an incontinence brief, and with a chest dressing falling off. The resident reported often waiting up to five hours without incontinence care and stated they only received a small wet towel bath rather than thorough cleaning. Review of this resident’s records showed difficulty determining if baths were provided as ordered, and documentation indicated multiple dates in January when no bed bath was given and only one documented bed bath in February. The DON and RCD acknowledged concern that the resident had not been receiving baths as ordered. Another resident, who was dependent on staff for ADL care, reported receiving showers only about every two months and expressed a desire for more frequent showers. Record review initially revealed no evidence that staff had provided baths or showers for this resident. The RCD stated that an error had occurred and that showers and baths had not been tracked. The DON later confirmed they were unable to provide evidence that the resident had received a bath or shower due to a system error in setting up showers and baths. Subsequently provided skin assessment sheets documented only a limited number of bed baths on specific dates in January and February, with no record of any showers and no additional bed baths beyond those listed.
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