Failure to Provide Timely ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide timely and necessary assistance with activities of daily living (ADLs) for two residents who were dependent on staff for care. One resident, with impaired thinking and memory, was found in a wet environment after their brief had been changed but the bed remained soaked with urine, indicating incomplete care. Staff interviews confirmed that the resident had not been changed for a while and was soaked through to the bed linens. The resident's care plan documented total dependence on staff for toileting and incontinence care. Another resident, also dependent on staff for all ADLs and with moderately impaired thinking, was left in soiled clothing and bed linen after vomiting, and was not changed for a significant amount of time. Staff interviews revealed that while rounds were conducted, the frequency and thoroughness of care varied depending on the resident's needs. The Director of Nursing Services acknowledged that the nursing staff did not meet the care needs of these residents, as required by their care plans and facility policy.