Failure to Provide Adequate Nail Care as Part of ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nail care as part of activities of daily living (ADLs) for two residents who were unable to perform their own hygiene. One resident had generalized muscle weakness, lack of coordination, cognitive communication deficit, toxic encephalopathy, type 2 diabetes mellitus, and morbid obesity, with an MDS BIMS score indicating moderate cognitive impairment and a care plan identifying ADL deficits related to weakness. Observations over several days showed this resident in bed with feet exposed and toenails that were yellow-brown, markedly overgrown, and curling over the tops and onto the pads of the toes on both feet. Despite an active order stating the resident "may see Podiatry of Choice" and shower sheets on two dates indicating that nails needed clipping, there were no orders or documentation for a podiatry visit, and the toenails remained long and discolored on repeated observations. Multiple staff interviews revealed inconsistent and unclear processes for nail care and referrals. A CNA stated that podiatry would be called to clip nails and that the approach depended on whether the resident was diabetic or if nails were long and curving. An RN reported not knowing the process for clipping nails and needing to ask the CNA. An LPN described a process that began with asking a CNA, then notifying the physician for a podiatry order for diabetic residents, and stated that responsibility for clipping nails belonged to all staff. The MDS coordinator indicated that long toenails identified on assessment would be referred to social services, while the social services director stated she only scheduled podiatry and other services for long-term residents and that case managers handled skilled residents. The case manager, however, stated that she did not schedule appointments and believed social services did, indicating a breakdown in role clarity and follow-through. The second resident had hemiplegia and hemiparesis following cerebral infarction, opioid dependence, cognitive communication disorder, and anxiety disorder, with an MDS BIMS score indicating severe cognitive impairment and dependence on staff for personal hygiene with assistance of one staff member per the care plan. During a dining room observation, this resident was seen eating with the left hand while fingernails were long and had food noted under them, and the feet were covered. A later observation showed that the fingernails had been clipped, but the resident had no shoes or socks on and toenails on both feet were long and extended over the ends of the toes. Review of this resident’s shower sheets showed they were not consistently completed regarding whether nails were clipped or needed clipping, and on one date a CNA marked that nail clipping was not needed. The facility’s ADL policy stated that if a resident is unable to carry out ADLs, necessary services to maintain grooming and personal hygiene would be provided by qualified staff, but the documented observations and records showed that nail care needs for these two residents were not met.
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