Failure to Provide ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for three dependent residents. One resident, admitted with generalized weakness and complex medical conditions, was found lying on her side with an untouched lunch tray out of reach. She reported waiting approximately thirty minutes for staff to return and assist her to a position where she could eat, as she was unable to do so independently. The call light and bed control were not accessible, and the resident was also found to be wet with urine. Staff confirmed the call light and bed control were not within reach, contrary to facility policy requiring these items to be accessible to residents in bed. Another resident, re-admitted with hemiplegia, aphasia, and dysphagia, was observed without a meal tray while her roommate was eating. Staff interviews revealed that this resident typically required substantial assistance with eating and had recently experienced significant weight loss. The resident was not initially offered lunch, and when a tray was eventually provided, the food was unappealing and refused by the resident. The care plan indicated the resident was dependent on staff for eating, but observations and interviews showed that assistance was not consistently provided. A third resident, with heart failure and end-stage renal disease, reported not consistently receiving scheduled showers. Documentation and interviews confirmed that showers were not always offered or documented as refused on the resident's preferred non-dialysis days, despite her requests. Review of shower records showed multiple missed or undocumented shower opportunities over several months, supporting the resident's claim that care was not provided as scheduled. These findings collectively demonstrate a failure to provide necessary ADL care and assistance to residents who were dependent on staff.