Failure to Provide Required ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for multiple residents who were unable to perform these tasks independently. Several residents with significant medical conditions, including chronic obstructive pulmonary disease, muscle weakness, dementia, hemiplegia, and dysphagia, did not receive scheduled showers, incontinence care, or proper assistance with positioning and feeding. Documentation was missing or incomplete for required care, and there was no evidence that residents refused these services. One resident, who required substantial assistance for toileting, dressing, and bathing, did not receive any showers as scheduled, despite being cognitively intact and expressing willingness to participate. Staff interviews confirmed that showers were not provided due to inadequate staffing, and documentation was sometimes falsified to indicate care was given when it was not. Another resident, dependent for toileting and dressing, was found with significant fecal incontinence that had not been addressed for several hours, resulting in soiled linens and discomfort. Staff could not confirm timely incontinence care, and records did not show refusals of care. Additional deficiencies included a resident with impaired mobility and swallowing difficulties who was not properly positioned for meals, leading to discomfort and missed meals. Staff failed to use prescribed positioning aids, and the resident's environment was left unclean after meal spills. Another resident reported not receiving scheduled showers, with staff citing lack of available personnel as the reason. Facility policies required documentation of care and refusals, but records were incomplete or missing, and staff interviews confirmed that care was not consistently provided as planned.