Failure to Provide Timely Assistance with ADLs and Nutrition Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received the necessary care and assistance to maintain good nutrition and personal hygiene. For one resident with diagnoses including non-Alzheimer's dementia, arthritis, and depression, documentation showed they required substantial to maximal assistance for toileting and transfers. On a specific date, there was no documented evidence that this resident was toileted during the day or evening shifts, with only night shift documentation present. Interviews with staff revealed that residents sometimes waited up to 45 minutes for toileting assistance, especially when staffing levels were low, and that the resident's family had complained about long wait times for care. Staff also indicated that the resident required a two-person assist for transfers and that delays occurred when a second staff member was not immediately available. Another resident, who was dependent on staff for all ADLs due to conditions such as seizures, diabetes, dysphagia, and a deep tissue injury, experienced a significant delay in receiving assistance with eating. Observations showed that the resident's lunch tray was delivered and left at the bedside, but the resident was not fed for over an hour. Documentation of meal intake was also incomplete for this resident, with many days left blank. Staff interviews confirmed that feeding could be delayed when there were only two aides on the unit, as showers and other care tasks took priority, and that documentation sometimes lapsed due to insufficient staffing.