Failure to Provide Required ADL Assistance and Supervision
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for two residents, resulting in deficiencies related to supervision during meals and incontinence care. One resident with a history of choking and muscle weakness was observed eating meals alone in their room, lying in bed with the privacy curtain drawn, making them not visible from the hallway. Despite care plans and the Kardex specifying the need for continual supervision during meals, staff allowed the resident to eat independently without supervision. Staff interviews revealed a lack of awareness regarding the resident's choking history and required level of supervision, with care plans and Kardex information not being consistently communicated or followed. Another resident, who was always incontinent of bladder and had moderate cognitive impairment, was not provided with timely incontinence care or prompted toileting. Observations showed that the resident spent extended periods in the dining room and hallways without staff offering assistance or asking about toileting needs, despite care plans and the Kardex indicating the need for supervision and assistance. The resident was observed expressing the need to urinate multiple times and eventually sought out a bathroom independently, only receiving assistance after staff were alerted by the surveyor. Documentation and staff interviews confirmed that regular bathroom rounds and prompts were expected but not consistently performed. The facility also failed to provide a policy on Activities of Daily Living when requested by the surveyor. Staff interviews indicated inconsistent knowledge and implementation of care plans and expected practices for both meal supervision and incontinence care. The Director of Nursing confirmed that staff were expected to follow care plans and provide the specified level of assistance, which was not done in these cases.