Failure to Respond Promptly and Provide Timely ADL Care for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to promptly respond to a dependent resident who was continuously yelling for assistance. Upon observation, three employees, including a CNA, a Nurse Manager, and a Unit Clerk, were seated at the nursing desk and did not respond to the resident's loud calls for help. Other residents and visitors in the area expressed concern about the yelling, but no staff intervened until much later. When the resident's room was entered, the individual was found poorly positioned in bed, with their head and lower extremities nearly off the mattress, and the call light was out of reach. The resident, who was incontinent and unable to reposition themselves, stated they needed to be changed and was found to have a wet brief. The call light was only activated by the surveyor, and staff did not respond until several minutes later. Interviews with staff revealed a lack of timely incontinence care and inadequate attention to the resident's needs. The assigned CNA confirmed that no incontinence care had been provided since the start of the shift, and the Unit Clerk, who was also a CNA, acknowledged the resident was wet and improperly positioned. Staff attributed the resident's yelling to behavioral issues and did not take immediate action, despite care plans indicating the need for call lights to be within reach and regular assistance with toileting and hygiene. Documentation for incontinence care was also incomplete for the day in question. The resident involved had a history of dementia, behavioral disturbances, incontinence, and required moderate assistance with activities of daily living. Care plans included interventions for communication, safety, and elimination needs, but there were no specific interventions for the resident's yelling behavior. Facility policy required repositioning of dependent residents at least every two hours, but this was not observed. The failure to respond promptly, provide timely incontinence care, and ensure proper positioning and access to the call light led to the identified deficiency.
Plan Of Correction
F0677 ADL Care Provided for Dependent Residents It is the practice of the facility to ensure that residents who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Element 1: Resident 410 remains in the facility and has been assisted with repositioning, ADL care, and call light placement at the time of the survey. The plan of care was reviewed and updated. Element 2: Residents who need staff assistance and/or positioning devices for proper positioning have the potential to be affected by the cited practice. An audit of residents requiring staff assistance and/or positioning devices for proper positioning was completed, and their care plans/Kardex were reviewed and updated, if applicable. An audit was completed to ensure call lights were within reach and residents who require staff assistance and/or positioning devices for proper positioning were in place. Element 3: The interdisciplinary team reviewed the "Activities of Daily Living" (ADL's), call light, incontinence care, and repositioning policies and procedures and deemed them appropriate for use as written. The facility licensed nurses and nursing assistants have been educated on the above policies. Element 4: The DON/designee will complete random audits weekly to ensure residents requiring staff assistance and/or positioning devices are properly positioned. The IDT team will complete random audits weekly to ensure call lights are within reach. The IDT team will complete random audits weekly to ensure residents calling out for assistance are responded to. Audits will be completed weekly for 4 weeks, then monthly for 3 months. Any deficient practice will be corrected/updated immediately. The results will also be taken to the QAPI meeting. Element 5: The Administrator is responsible for compliance: date of compliance May 6, 2025.