Failure to Provide Timely ADL Assistance and Scheduled Showers
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for two residents who required substantial help, resulting in unmet care needs. One resident with severe cognitive impairment, frequent incontinence, and a care plan requiring substantial assistance with toileting repeatedly requested help to use the bathroom over a 33-minute period. Despite her visible distress and repeated verbal requests to multiple staff members, she was not assisted in a timely manner. Staff were observed prioritizing feeding other residents and charting over responding to her toileting needs, and the resident ultimately urinated on herself while waiting for assistance. Interviews with staff confirmed that staffing shortages and task prioritization contributed to the delay, and documentation indicated that the resident was found with soiled clothing and incontinence products after the incident. Another resident, who was dependent on staff for bathing and required two-person assistance with transfers, did not receive scheduled showers for two separate six-day periods. The resident reported not having received a shower in two to three weeks, despite a physician's order for twice-weekly showers. Documentation errors were identified, with a CNA admitting to mistakenly recording showers that did not occur. There was also no documentation to support claims that the resident received bed baths during the missed shower periods. Staff interviews revealed that showers were often scheduled late at night, which may have contributed to missed care, but the resident denied refusing showers. The facility's own bathing policy requires regular and as-needed bathing assistance, but this was not followed for the residents in question. Staff and management acknowledged that the expected frequency of showers was not met and that residents should have been offered alternative hygiene care when showers were missed. The deficiencies were substantiated through direct observation, resident and staff interviews, and review of care plans and documentation.