Failure to Provide Consistent ADL Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide timely and consistent assistance with activities of daily living (ADLs) for a resident who was dependent on staff for bathing, grooming, and dressing due to impaired mobility from multiple fractures and moderate cognitive impairment. The resident was scheduled to receive showers twice weekly, but records showed that she was not offered a shower for 3 out of 7 scheduled opportunities within a specified period, and did not receive any unscheduled showers. Interviews with family, staff, and the resident confirmed that she often remained in bed, was not dressed or groomed, and missed scheduled showers, particularly during periods of low staffing, especially on weekends. The resident expressed frustration and embarrassment about her appearance when not assisted with bathing and grooming, and reported back pain from remaining in bed too long. Family members and staff corroborated that the resident's personal hygiene and grooming needs were not consistently met, and that these lapses were linked to staffing shortages. Facility policy required that residents unable to perform ADLs independently receive necessary services to maintain hygiene and dignity, but this was not consistently implemented for the resident in question.