Failure to Provide Timely ADL Assistance and Personal Hygiene Care
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. One resident's breakfast tray was left unopened on her bedside table for 30 minutes before staff arrived to assist, despite her documented need for help with meals due to moderate cognitive impairment and a history of traumatic brain injury. Multiple staff interviews confirmed that facility policy requires residents needing assistance to be fed immediately when the tray is delivered, and that leaving the tray unattended could result in the food becoming cold and unappetizing. Another resident was observed with a significant buildup of brown/yellow substance on his teeth during two separate observations. The resident expressed a desire for oral care and stated it had been a while since anyone had offered to clean his teeth. Staff confirmed that oral care should be provided daily and acknowledged the presence of buildup, which could lead to dental issues. This resident also had moderate cognitive impairment and required assistance with personal care due to hemiplegia, muscle contractures, and generalized muscle weakness. A third resident was found with long, jagged, and dirty fingernails, as well as visible facial hair on the cheeks, chin, and upper lip. Staff confirmed that the resident's nails and facial hair should have been trimmed and cleaned, noting that long nails could harbor bacteria and cause skin tears, and that facial hair should be shaved regularly. This resident was dependent on staff for personal hygiene and had moderate cognitive impairment related to vascular dementia and epilepsy.