Failure to Provide Timely ADL Assistance and Personal Care
Penalty
Summary
The facility failed to provide adequate Activity of Daily Living (ADL) assistance to 15 out of 22 residents, as evidenced by prolonged response times to call lights and insufficient personal care. Residents reported waiting an hour or longer for assistance, which was corroborated by a resident group interview and confirmed by the Director of Nursing. The facility's policy mandates that calls for assistance should be answered within five minutes, but this was not adhered to, leading to resident frustration and complaints during resident council meetings. Additionally, residents expressed dissatisfaction with agency staff, citing inattentiveness and lack of care. Specific instances of neglect included a resident waiting for their laundered clothes, resulting in wearing ill-fitting facility clothing, and another resident having long, unkempt fingernails and being malodorous. One resident was observed without pants, expressing discomfort, while another reported receiving only two showers since admission, despite being scheduled for regular showers. These observations and interviews highlight the facility's failure to meet the necessary ADL care requirements, as confirmed by the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
Immediate Intervention: Call light box was inspected and found to have a burnt-out bulb and bulb was replaced immediately. R68 clothes were discovered in laundry and returned to R68 and nail care and hygiene were provided. R125 nail care provided. R08 lower body was dressed. R69 shower was provided. Identification of other residents who potentially can be affected: All residents were identified to potentially be affected. Prevention of further occurrence: Education to resident rights as it pertains to resident ADL care. Educate staff about ADL resident rights and call light system. Corrective Action to be monitored: Audit tool created and DON or designee to assess residents' hygiene and shower schedule for compliance. QA Program: 3 residents on each unit will be audited (to assess residents' hygiene and shower schedule for compliance) daily for five days, weekly for three weeks, and monthly for three months. The identification of non-compliance staff will result in a performance improvement plan with potential for corrective action and discipline. Results of shower compliance added to monthly QAPI.