Failure to Provide Timely ADL and Incontinent Care
Penalty
Summary
A resident with hemiparesis and vascular dementia, who required maximal assistance with activities of daily living (ADLs) and was frequently incontinent, did not receive timely personal and incontinent care as required by their care plan. Documentation and staff interviews revealed that the resident was not provided morning care until the afternoon, despite having their call light on for an extended period and requesting assistance. The nurse aide assigned to the resident failed to perform regular two-hour checks and did not provide morning ADL care, only attending to the resident after a supervisor intervened. The aide also provided care alone, despite the resident's care plan specifying the need for two staff members due to left-sided weakness. Further review showed that the last documented incontinent care was provided early in the morning, with no evidence of care between 7 AM and 3 PM. The nurse aide admitted to not providing morning care and to being unfamiliar with the assignment, which she found heavy. Other staff, including an LPN, entered the resident's room for medication administration but did not check for incontinence or provide personal care. Facility leadership confirmed that required two-hour rounds and morning care were not conducted as per policy, resulting in the resident not receiving necessary care in a timely manner.