Failure to Provide Timely ADL Care and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to provide timely care and assistance with activities of daily living (ADLs), including repositioning, brief changes, and ensuring call light accessibility, for three dependent residents. Observations revealed that residents with severe cognitive impairment and physical limitations, such as those with diagnoses of non-traumatic brain dysfunction, stroke, high blood pressure, Alzheimer's, anxiety, depression, and dementia, were left in bed for extended periods without being repositioned or assisted out of bed. In multiple instances, residents' call lights were found out of reach, placed in closed drawers, and not accessible to the residents, despite facility policy requiring call lights to be within reach and functioning. One resident was observed multiple times over several days lying supine in bed, dressed in a hospital gown, with their breakfast tray untouched and the call light inaccessible. The resident expressed a desire to be out of bed but was not observed to have been assisted with transfers or repositioning, and staff confirmed the resident required a Hoyer lift and two-person assistance. Another resident was observed with long, dirty fingernails, a saturated brief, and reported not having been changed or repositioned recently. Staff interviews confirmed knowledge of the facility's two-hour repositioning and brief change policy, but observations indicated these standards were not consistently met. Additionally, a third resident was observed repeatedly activating their call light to request a brief change, but staff deactivated the call light without providing care and left the room. Agency staff admitted to not knowing the call light policy. Resident council meeting minutes documented ongoing concerns about untimely call light responses and lack of care. Interviews with nursing leadership confirmed expectations for timely call light response and care provision, but these were not consistently followed as evidenced by the observations and resident reports.