Failure to Provide Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) such as bathing, grooming, dressing, oral hygiene, and getting out of bed for several residents who were dependent on staff for these tasks. Observations and interviews revealed that multiple residents remained in bed in hospital gowns, with unkempt hair and unbrushed teeth, and did not receive scheduled showers or assistance with dressing as outlined in their individualized care plans. Staff interviews confirmed that required morning care, including oral care, hair care, dressing, and assistance to get up, was not consistently provided, and that refusals of care were not documented as required by facility policy. One resident with complex medical conditions was observed multiple times in bed, unshaven, with greasy hair and unbrushed teeth, and reported not receiving help with oral hygiene. Another resident, who required maximal assistance and use of a mechanical lift, was observed in bed during multiple visits and was not assisted to get up for meals or activities as specified in their care instructions. A third resident, dependent for all cares due to stroke and dementia, had no documentation of bathing being offered or provided for several months and was not assisted out of bed except for a medical appointment. Staff confirmed that these residents should have received regular assistance with ADLs but did not, and there was no documentation of refusals. Additional residents also reported or were observed not receiving scheduled showers or assistance with dressing and hygiene. One resident expressed frustration at not receiving showers as scheduled, and documentation confirmed that only half of the scheduled showers were provided, with no refusals documented. Staff interviews further corroborated that expected care was not consistently offered or documented. These failures were in direct violation of the facility's ADL policy and care plans, leaving residents without the necessary support for their daily living needs.