Failure to Provide Required ADL Assistance and Supervision
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were dependent on staff support. One resident, who was moderately cognitively impaired and required total assistance for transfers, was observed repeatedly left in their wheelchair for extended periods, including while asleep, without being assisted back to bed as requested by their representative. Staff interviews confirmed that the resident was routinely kept in their wheelchair after breakfast until the afternoon, despite expectations that staff should assist residents to lie down if they were asleep in their wheelchair. Another resident, dependent on staff for bathing, dressing, and personal hygiene due to impaired balance and diabetes, reported that staff did not provide nail care, did not offer washcloths for personal hygiene, and did not remove their socks for weeks. Observations confirmed the resident had long, cracked toenails and dry, discolored skin on their feet, with one leg more swollen than the other. Staff interviews revealed that refusals of care were not documented, and the resident was not referred to the podiatrist for diabetic foot care as required, nor was there evidence of proper communication among staff regarding the resident's needs. A third resident, who had recently transitioned to hospice care and required supervision while eating, was observed multiple times with meal trays but without staff supervision during meals. On one occasion, the resident was heard coughing while eating alone, and staff did not provide the required supervision. Staff interviews indicated a lack of awareness of the resident's current care plan, with some staff believing only setup assistance was needed, despite documentation requiring supervision. These failures were contrary to the facility's own ADL policy and placed residents at risk for unmet care needs.