Failure to Provide Consistent ADL Support and Reliance on Family for Care
Penalty
Summary
Staff failed to ensure that two residents received assistance with basic activities of daily living (ADLs), such as hair and oral care, as well as support to get out of bed and participate in meals and social activities. One resident, who had a history of stroke and was unable to brush the right side of her hair, reported that her face was only sometimes washed in the morning and her hair was only partially brushed. Observations confirmed that her hair and teeth were not consistently cared for, and a staff member noted that they often provided these cares only when a family member was present, raising concerns about what would happen if the family member did not visit daily. Another resident was frequently left in her room in the dark during breakfast, not encouraged to get out of bed, eat, or socialize with others. Observations showed that her hair remained in frizzy braids that appeared to have been slept in throughout the morning. Staff interviews revealed a pattern of relying on family members to complete basic ADLs, rather than ensuring staff provided these essential cares.