Failure to Provide and Document Adequate ADL and Incontinence Care
Penalty
Summary
Facility staff failed to provide appropriate activities of daily living (ADL) and incontinence care for multiple dependent residents, as evidenced by observations, interviews, and record reviews. One cognitively intact resident with an indwelling Foley catheter and dependence for toileting hygiene, bathing, and footwear was observed receiving a bed bath and incontinence care that did not follow basic hygiene practices. The CNA removed dirty linens without using a bed/bath blanket or towel, leaving the resident exposed throughout the bath, used only one basin of water, washed the resident’s upper body and lower extremities, and then dried the resident without rinsing off soap. The CNA then removed the resident’s brief and used the same soapy washcloth that had been used for the body bath to clean the perineal area after a bowel movement before discarding it, and later stated she had been taught to provide bed baths in this manner. Another cognitively intact resident with a need for assistance with personal care and an overactive bladder, who required setup or cleanup assistance for bathing, oral hygiene, and personal hygiene, was observed with medium-length chin hair. During interview, this resident stated she wanted both her hair and chin/facial hair trimmed. Staff interviews confirmed that removal of facial or chin hair is considered part of ADL care and should be provided during scheduled showers twice weekly, but the resident’s facial hair had not been addressed. A different dependent resident with severe cognitive impairment and urinary incontinence, who was coded as dependent for eating, oral hygiene, toileting, bathing, and personal hygiene, reported through her daughter that she wanted more showers and hair washing. The daughter produced a modified bath basin she used at bedside to wash her mother’s hair because, according to her, staff would not wash it. Review of ADL documentation showed the resident was scheduled for baths/showers twice weekly, but records for December and January reflected missed or reduced bathing, including days with no documented baths/showers and a pattern of only one shower per week over a two‑month period. Additional dependent residents with significant ADL self-care deficits had missing documentation for hygiene and incontinence care on multiple dates and shifts. One resident with CVA, diabetes, epilepsy, hemiplegia, impaired balance, and limited mobility, who was dependent for mobility, transfers, bathing, dressing, and toileting, had gaps in ADL records for hygiene and bowel/bladder continence across several days and shifts in December and January. Another resident with impaired mobility, maximal assist needs for bed mobility, transfers, and hygiene, and intact cognition had missing documentation for hygiene and bowel/bladder continence on multiple January shifts. A further resident with schizoaffective disorder, depression, severe cognitive impairment, and a need for one-person assistance with personal hygiene had extensive blanks on ADL tracking sheets for personal hygiene over numerous consecutive days in November and December, covering all shifts. CNAs and an RN stated that hygiene and incontinence care are documented in the electronic ADL system and that missing documentation means care was not done, but one CNA also stated she did not know what the blanks indicated, and no additional information was provided before survey exit to clarify or reconcile these omissions.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.