Failure to Provide Required ADL Care to Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to provide necessary activities of daily living (ADL) care to a resident who was totally dependent on staff for self-care. The resident, admitted in 2017 with a diagnosis including Multiple Sclerosis, was assessed as cognitively intact and fully dependent for self-care according to the most recent MDS assessment. On the evening in question, the resident's nurse identified that the resident needed to be changed after a bowel movement and instructed the assigned geriatric nursing assistant (GNA) to provide care. However, the GNA did not perform the required care, only emptying the resident's urinary catheter and failing to recognize the need for further assistance. The lapse in care was discovered when the next shift's GNA entered the resident's room and noted a strong odor, with the resident reporting that the previous GNA had not provided the necessary care. Facility investigation and interviews confirmed that the resident did not receive the required ADL care during the 3 PM to 11 PM shift. The administrator acknowledged that staff failed to provide the needed care for the resident during this time period.