Failure to Provide Required Assistance with Eating and Toileting
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for two residents, specifically in the areas of eating and toileting. One resident with severe cognitive impairment and a history of dysphagia was observed attempting to eat and drink independently without staff supervision or assistance, despite care plan and therapy notes indicating the need for feeding assistance and aspiration precautions. On multiple occasions, the resident was left alone in the dining area, struggled to eat, and experienced frequent coughing episodes. Interviews with staff confirmed inconsistent understanding and implementation of the required level of supervision and assistance for this resident during meals. Another resident, who was cognitively intact but had muscle weakness and depression, was found lying in bed with a soiled brief containing bowel movement that had not been changed for an extended period. The brief was marked with a time indicating it had not been changed for several hours, and the resident confirmed that no staff had assisted her throughout the day. Multiple staff interviews corroborated that the resident had not received timely toileting care as outlined in her care plan, which required regular checks and changes every two hours. The facility's failure to provide timely and appropriate assistance with eating and toileting for these residents was confirmed through observations, interviews, and record reviews. The lack of adherence to care plans and staff uncertainty regarding required interventions contributed to the deficiencies identified during the survey.