Failure to Provide Assistance with Activities of Daily Living Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to six residents who were unable to perform these tasks independently, as required by their care plans. Observations and interviews revealed that residents did not consistently receive help with bathing, toileting, and personal hygiene. Documentation showed missed or undocumented showers, and residents reported long waits for assistance or having to perform tasks themselves due to staff shortages. For example, one resident with severe cognitive impairment was observed repeatedly asking for help to go to bed and remained in the dining room for several hours without being assisted to the toilet. Another resident reported not being bathed for two weeks and having to wait extended periods for toileting assistance. Record reviews indicated that scheduled showers were frequently missed or not documented for multiple residents, despite their care plans specifying the need for staff assistance. Several residents, both cognitively intact and impaired, described having to wait for long periods or not receiving showers according to their preferences or schedules. Staff interviews confirmed that staffing shortages contributed to delays and missed care, with some residents having to wait until after midnight to be put to bed or having to perform sponge baths independently due to lack of help. Facility documentation further revealed inconsistencies in the recording of ADL care, with many entries marked as "not applicable" or lacking any documentation for scheduled showers. Residents' accounts and staff interviews consistently pointed to a pattern of insufficient staffing leading to unmet care needs, particularly in bathing and toileting. The lack of a functional bathtub was also noted, requiring all residents to use showers, which may have further impacted the facility's ability to meet residents' bathing preferences and schedules.