Failure to Provide Consistent ADL Care and Proper Feeding Technique
Penalty
Summary
The facility failed to provide consistent care and assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. The resident, who had a history of severe cognitive impairment, stroke with resulting hemiplegia and hemiparesis, aphasia, dysphagia, end-stage renal disease, and dependence on dialysis, required substantial to maximal assistance with all ADLs, including bathing, grooming, oral hygiene, dressing, and feeding. According to the care plan and ADL schedule, the resident was to receive bed baths three times per week and assistance with grooming and hygiene. However, documentation and family interviews indicated that bed baths and grooming were not provided consistently according to the schedule, and the resident was observed with disheveled and matted hair on multiple occasions. Photographs provided by the family showed the resident with exposed upper chest and shoulder, and her hair in poor condition, suggesting lapses in personal care and dignity. Additionally, the report documents that a Licensed Vocational Nurse (LVN) was observed standing while feeding the resident, contrary to facility policy and in-service training, which require staff to be seated while feeding residents to reduce the risk of choking and aspiration. The LVN acknowledged having received training on proper feeding techniques but admitted to standing while feeding the resident on at least one occasion, as confirmed by video footage provided by the family. Interviews with staff and administration confirmed that the expectation is for staff to sit while feeding residents, and that standing while feeding poses a risk to resident safety. The facility's own records, including shower sheets and grievance logs, corroborated the family's concerns about inconsistent ADL care. The resident's family filed a grievance on the day of discharge, citing inadequate assistance with personal hygiene and grooming. Staff interviews revealed that while some ADL care was documented, there were discrepancies between staff accounts and the family's observations, particularly regarding the resident's grooming and the manner in which feeding assistance was provided. The facility's policies require individualized care based on comprehensive assessment, but the observed and reported deficiencies indicate that these standards were not consistently met for this resident.