Failure to Provide Timely ADL Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. The resident, who had diagnoses including acute respiratory failure, irritable bowel syndrome, osteoarthritis, and a history of pneumonia, required substantial to maximal staff assistance for transfers and toileting, as documented in her care plan and MDS assessment. Despite this, observations showed that the resident was not offered repositioning or toileting assistance for a period of nearly four hours. During this time, the resident remained in bed and was not checked by staff, even when visited by the nursing home administrator, who did not inquire about her need for repositioning or toileting. The resident reported that she needed to be checked every two hours for toileting assistance but stated that staff did not check on her, leading her to limit her fluid intake. Continuous observation confirmed that the resident was not provided incontinence care from 12:30 p.m. to 4:12 p.m., and when staff finally responded to her call light, her brief was found to be saturated with urine. Staff interviews confirmed that residents requiring assistance should be checked every two hours, and failure to do so could result in negative outcomes. The care plan also indicated the need for staff assistance with repositioning, which was not provided during the observed period.