Failure to Provide Timely ADL and Meal Assistance
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. One resident with severe cognitive impairment, quadriplegia, and incontinence was observed for multiple periods exceeding three hours without being offered repositioning or toileting assistance, despite care plans and staff interviews confirming the need for two-hour checks to prevent skin breakdown. Staff were unaware that the resident had not been changed for extended periods, and documentation of care provided was lacking. Two other residents, both with cognitive impairment and requiring assistance or encouragement with eating, did not receive timely meal assistance. One resident, who required her meat to be cut and needed verbal cueing, was served meals without appropriate preparation and did not receive encouragement or alternatives when she consumed less than 25% of her meal. Staff also failed to document meal intake accurately, and no alternative meals were offered as required by her care plan and physician's orders. The third resident, who had severe cognitive impairment and was missing dentures, required set-up assistance and encouragement during meals. Observations showed that she was not encouraged to eat the main portion of her meals, was not offered alternatives when she did not eat, and was routinely given dessert or ice cream instead of a nutritional alternative. Staff interviews confirmed that encouragement and alternative options were not consistently provided, and the resident's representative noted a lack of staff engagement during meals.