Failure to Provide Timely ADL Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide timely care and assistance for activities of daily living to residents who are unable to perform these tasks themselves. Resident #5, who is dependent on staff for all activities of daily living due to multiple medical conditions including dysphasia, hemiplegia, and metabolic encephalopathy, was observed lying in bed with a wet adult incontinent brief. Staff E admitted that the last care provided to the resident was approximately four hours prior to the observation, indicating a significant delay in care. Resident #1 was found unresponsive in bed by paramedics, with old urine soiling his clothing and bed sheets. Despite being treated for the flu and a urinary tract infection, the facility staff were unable to determine how long the resident had been unresponsive. Interviews with staff revealed inconsistencies in care documentation and a lack of timely incontinence care, as the Activities of Daily Living Task sheet showed no documentation for two consecutive days. A confidential random resident reported issues with night shift staff, stating that after requesting assistance for incontinence, staff delayed care for four hours. This indicates a pattern of inadequate and delayed care for residents requiring assistance with personal hygiene and incontinence management, contributing to the facility's failure to meet the necessary standards of care.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 no longer resides in the facility as of Resident #5 was assessed On by nursing no negative outcomes observed. Confidential/random resident: On a current audit was conducted on current residents to ensure no issues related to ADL care were identified, no like residents noted. 2. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. By an audit was completed by the DON/designee on current residents identified as dependent for ADL care, any concerns identified were addressed at the time of assessment. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. By current nursing staff were educated on ADL care for dependent residents by the Assistant Director of Nursing/Designee. Newly hired staff will be educated on ADL care for dependent residents by the Assistant Director of Nursing/Designee at orientation as part of the systematic changes. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. The DON/Designee will audit 5 residents receiving ADL care 2x week x 4 weeks then 1x week for 4 weeks then 2 x month for x 1 month then monthly for 1 month to ensure substantial compliance is achieved. The findings of these audits will be reviewed in the monthly QAPI meeting.