Failure to Provide Required ADL Assistance and Positioning
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for two residents with severe cognitive and physical impairments. One resident, diagnosed with epilepsy, dysphagia, and dementia, was documented as being dependent on staff for eating and other ADLs. Despite this, multiple observations showed the resident left unattended during meals, struggling to eat a pureed diet without staff assistance or encouragement, even though the care plan and assessments clearly indicated a need for substantial to maximum assistance. Another resident, with diagnoses including Alzheimer's disease, congestive heart failure, and dysphagia, was also dependent on staff for ADLs and required specific positioning and footwear for safety and comfort. Observations revealed this resident was transported in a wheelchair without socks or appropriate footwear, and the footrest was not positioned correctly, leaving her feet dangling and uncovered. The care plan specified the need for bilateral lower extremity support and appropriate footwear, but these interventions were not provided as required. Interviews with staff confirmed that care plans and the Kardex were available to guide the level of assistance needed, and that it was the staff's responsibility to ensure residents received the necessary support. Facility policy required that residents unable to perform ADLs independently must receive services to maintain nutrition, hygiene, and comfort, but these requirements were not met for the two residents observed.