Failure to Provide Adequate Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several dependent residents, including assistance with toileting, turning and repositioning, queuing for food and hydration, and personal hygiene. One resident with severe cognitive impairment, hemiplegia, and on hospice care was repeatedly observed lying in bed for extended periods without being offered food, fluids, or assistance. Meal trays were left untouched and removed without staff attempting to queue or assist the resident, and her water pitcher was not refreshed. The resident was frequently found in soiled clothing and bedding, with matted hair that eventually required cutting due to lack of care. Multiple interviews with hospice staff, family members, and facility staff confirmed ongoing issues with personal care, hydration, and communication between facility and hospice staff. Another resident, who was cognitively intact but physically dependent, reported frequent delays in staff response to call lights, resulting in episodes of incontinence and feelings of neglect. He stated that staff rarely offered to take him to the toilet and only changed his brief upon request, sometimes after significant delays. Family members corroborated these accounts, describing long waits for assistance and inadequate hygiene care, such as only having his face washed in the morning and infrequent bathing. A third resident, who was transferred to another facility, was found with dried feces on her back, dirty feet, matted hair, and body odor, and reported not having had a shower in three months. Her personal care assistant and family members noted repeated issues with lack of hygiene and long waits for staff assistance. Another dependent resident was observed with visible facial hair that was not addressed by staff, despite family requests and care plan instructions. Staff interviews revealed a lack of clarity and consistency in providing grooming and personal care, with some staff unaware of or not performing required tasks. The facility lacked documented audits or oversight to ensure that ADL care was being provided as required.