Failure to Provide Timely ADL Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was totally dependent on staff for activities of daily living (ADL) did not receive timely care as required by the facility's policy and the resident's care plan. The resident, who had diagnoses including morbid obesity, Type 2 Diabetes with polyneuropathy, and an acquired absence of the right leg below the knee, was nonambulatory and required a two-person assist with a mechanical lift for transfers, as well as total assistance for bathing, grooming, positioning, and toileting. On the evening in question, the resident requested care after being incontinent, but staff did not provide the necessary assistance until the following morning. Interviews and record reviews revealed that the resident requested care around 11:00 P.M. after an episode of incontinence. The assigned CNA informed the resident that he could not provide care alone and needed to wait for another staff member. The nurse on duty was aware of the request but did not ensure care was provided before the end of her shift, nor did she assist or seek help from another nurse. During the night shift, only one CNA was present instead of the scheduled two, and the CNA continued to wait for assistance that did not arrive until approximately 5:00 A.M. Despite the resident's repeated requests, care was not provided until the day shift arrived. When the day shift nurse and CNA responded to the resident's call light around 8:00 A.M., they found the resident had a bowel movement that appeared to have been present for many hours. The Director of Nursing confirmed that staff should have clarified the resident's needs and provided timely care in accordance with the care plan. The lack of communication and failure to provide necessary assistance resulted in the resident remaining without incontinence care for approximately nine hours.