Failure to Provide Proper ADL Assistance and Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received the necessary services to maintain proper personal hygiene. Specifically, staff did not use a gait belt when transferring a resident with dementia, a history of falls, and abnormal gait from a recliner to a wheelchair, despite the resident requiring assistance for transfers and being at risk for falls. During a subsequent transfer, although a gait belt was applied, staff did not use it correctly and instead lifted the resident by the shoulders, contrary to facility policy and professional guidance. For another resident with severe cognitive impairment and total dependence on staff for ADLs, staff failed to use a Hoyer lift sling according to manufacturer guidelines during a transfer from wheelchair to bed. The lower straps of the sling were not crossed as required, and incontinence care was delayed for nearly four hours, resulting in the resident remaining in a heavily saturated brief. Additionally, staff did not follow proper perineal care technique, using the same disposable cloth for multiple wipes and failing to perform hand hygiene before repositioning the resident. A third resident, also with severe cognitive impairment and total incontinence, was not offered or provided incontinence care for almost four hours while in common areas. Staff repositioned this resident in her wheelchair by hooking their arms under her armpits, which is not in accordance with safe transfer practices. The care plans for both residents required regular incontinence checks and assistance, but these interventions were not consistently implemented as observed during the survey.