Failure to Provide Timely ADL Assistance According to Resident Preferences
Penalty
Summary
Staff failed to provide timely assistance with activities of daily living (ADLs) according to the preferences of a resident who was dependent on staff for oral care, pericare, and personal hygiene. The resident, who had diagnoses including paraplegia, pressure ulcers, colostomy, and urostomy, was cognitively intact and had clearly communicated a preference to receive morning care around 10:00 AM. Despite this, documentation and interviews revealed that the resident received assistance with ADLs during the morning shift only 26% of the time over a one-month period. The resident repeatedly used the call light and requested care, but staff often delayed assistance until the PM shift, leaving the resident without timely hygiene and care as needed. The facility's policy required timely and consistent assistance with personal hygiene and prompt response to call lights, but staff did not consistently follow these protocols for this resident. The resident filed a grievance regarding the lack of timely care, and although the facility indicated the issue was resolved and staff were educated, the resident reported that the problem persisted. Interviews and record reviews confirmed that the resident continued to experience delays in receiving care, including oral hygiene and changes of incontinence pads, particularly during the morning hours as per the resident's stated preference.