Failure to Provide Timely ADL Assistance and Personal Hygiene
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. For two residents, staff did not provide timely incontinent care. One resident, a male with a history of ventilator dependence, hypertension, and gastrostomy, was found with a saturated and soiled brief, a strong ammonia odor in the room, and a soaked draw sheet. Staff interviews revealed that required two-hour rounding and incontinent care were not performed as scheduled, with the CNA citing being overburdened with other residents and tasks. The nurse and unit manager confirmed that the resident was at risk for skin breakdown due to the lack of timely care. Another resident, a female with diagnoses including colon cancer, hypertension, atrial fibrillation, and cognitive communication deficit, also did not receive timely incontinent care. She reported feeling wet and neglected, and observation confirmed her brief was saturated with urine and bowel movement, with soiling extending to the draw sheet. Staff interviews indicated that the resident had not been changed for several hours, and the CNA responsible stated she was doing her best given her workload. The DON and medical director acknowledged that the lack of timely care placed the resident at risk for skin maceration and breakdown. A third resident, a female with ventilator dependence, tracheostomy, hypotension, and cognitive communication deficit, was observed to have long, classified toenails. Staff interviews revealed that aides had reported the issue to nursing staff weeks prior, but no action was taken to address the toenails. There was confusion among staff regarding responsibility for toenail care, especially after the resident was placed on hospice care. The DON, unit manager, and ADON all acknowledged the risk posed by the long toenails, but there was no documentation or follow-up to ensure the resident received appropriate grooming and personal hygiene.