Failure to Provide Adequate ADL Support and Hygiene
Penalty
Summary
Facility staff failed to provide adequate care and assistance with activities of daily living (ADLs) for two residents who required substantial help due to severe cognitive and physical impairments. One resident, admitted with diagnoses including stroke, hemiplegia, aphasia, and muscle weakness, was observed multiple times over two days wearing the same food-stained blouse and lying in soiled bedding. Staff were seen attempting to feed the resident while she was not fully alert, resulting in food spilling onto her clothing and bedding, which were not changed afterward. Incontinence care was provided without changing the soiled linens, and staff admitted unfamiliarity with the residents due to being assigned to a different unit. Another resident with severe dementia, pneumonia, spinal fracture, and atrial fibrillation was found by his daughter in a completely soaked incontinent brief, which she had to change herself after multiple unsuccessful attempts to get staff assistance. The resident was also observed wearing the same shirt over several days, with documentation indicating no staff assistance was provided for dressing or toileting, despite care plans identifying a need for hands-on help. Staff interviews revealed a lack of knowledge about the residents' care needs, with some staff stating they did not usually work in the assigned hallway and were unsure if residents' clothing or bedding had been changed. Documentation and direct observations confirmed that both residents did not receive necessary hygiene, dressing, and incontinence care as required by their conditions and care plans. The facility's failure to provide appropriate ADL support resulted in residents remaining in soiled clothing and bedding, and in one case, a family member having to intervene to address basic care needs.