Failure to Provide and Accurately Document ADL Hygiene and Bathing Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and accurately document assistance with activities of daily living (ADLs), specifically hygiene and bathing, for multiple residents. For one resident, review of hygiene task documentation on a specific date showed oral care marked as “not applicable” without any indication that care was refused, making it appear that no attempt was made to provide oral care. Another resident was observed to have severe plaque buildup on their teeth despite a care plan that required teeth brushing twice daily. During an interview, the DON confirmed that staff were incorrectly selecting “not applicable” instead of documenting when a resident refused care, which made it appear that required care was not provided rather than refused. A third resident’s MPOA reported that the resident often appeared unkempt and that she frequently had to remind staff of the resident’s scheduled shower days; she stated that both she and the resident preferred showers and that staff were aware. Record review showed this resident required assistance or was dependent for multiple ADLs, including bathing, grooming, and personal hygiene, and that it was important to the resident to have a shower. The resident had diagnoses of Dementia and Parkinson’s Disease and was scheduled for showers twice weekly on day shift. Over a 30‑day period, the resident was eligible for eight showers but received three showers and two bed baths, with several scheduled shower days documented as “not applicable.” The DON confirmed that the resident did not receive showers as scheduled.
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