Failure to Provide ADL Assistance to Dependent Residents
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs) for three residents who required varying levels of support. One resident, who required moderate to maximum assistance with all self-care, was not shaved by staff during his stay, despite repeated requests from his spouse. Documentation and interviews confirmed that staff were hesitant to shave him, and the issue was only addressed on the day of discharge, after a grievance was filed. Another resident, who had significant upper extremity impairments and required setup or clean-up assistance for eating, did not receive the necessary support during a meal. The resident was found upset, unable to access or eat her breakfast due to missing utensils, unopened food items, and the absence of milk for her cereal. The dietary manager confirmed the deficiencies in meal setup and food quality, and the resident's clinical record supported her need for assistance. A third resident, who required extensive two-person assistance for bed mobility, transfers, and toileting, reported not receiving care for over two and a half hours despite repeated use of the call bell. The resident and her roommate remained in their wheelchairs all day, resulting in pain and distress, and the resident's son ultimately called 911 for help. Documentation for the relevant shift was blank, and staff interviews confirmed that lack of documentation indicated care was not provided. No grievance was filed for this incident, and facility leadership was unaware of the event until informed by surveyors.