Failure to Provide Adequate ADL Assistance and Catheter Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents who were dependent on staff for care. One resident, who had severe cognitive deficits, post-polio syndrome, and was non-ambulatory, was observed multiple times in a wheelchair with her feet dangling unsupported and without a padded footrest as directed in her care plan. She was also found sitting in a urine-saturated brief, and during a transfer with a mechanical lift, urine spilled from her clothing and pooled in the wheelchair and on the floor. Staff interviews revealed that this resident was routinely awakened and transferred to her wheelchair before 6:00 AM, often left to sleep in the chair, and not always provided with timely toileting or repositioning as required by her care plan and facility policy. Another resident, who had moderate cognitive deficits and an indwelling Foley catheter, was found in bed with the catheter drainage bag hanging on the bedrail above the level of his bladder, contrary to infection control guidelines and facility policy. Nursing notes indicated that this resident had experienced issues with catheter blockage, cloudy urine, and was treated for a urinary tract infection. Staff acknowledged that the catheter bag should be kept below the bladder to prevent backflow and potential infection, but this was not done during the observation. Facility policies required incontinent residents to be checked and changed every two hours and for catheter care to be provided every shift. Despite these policies, direct observations and staff interviews confirmed that care was not consistently provided as required, resulting in residents being left in soiled briefs, improperly positioned, and with improper catheter management.