Failure to Provide Required ADL Care Resulting in Resident Neglect
Penalty
Summary
A staff member failed to provide necessary activities of daily living (ADL) care to a dependent resident who required full assistance for ambulation and brief changes. Despite being instructed by a nurse to change the resident's soiled brief, the staff member did not perform the task and left the shift. The resident was later found with dried feces up his back, on his clothing, in his wheelchair, and under the wheelchair cushion. Witness statements confirmed that the staff member did not spend sufficient time to properly change the resident and that the odor of soiling was noticeable to other staff in the area. The incident was reported as neglect of care, and it was determined to be an isolated event involving this particular resident and staff member, rather than a systemic issue. The staff member in question had a history of performance issues and was on administrative leave at the time of the investigation. Facility policies reviewed defined neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and included toileting as a required ADL service.