Failure to Provide ADL Assistance, Incontinence Care, and Meal Support
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for three residents who were dependent on staff. One resident with dementia, contractures, dysphagia, aphasia, and a stage 4 sacral pressure ulcer was observed to have not received assistance with lunch, as her meal tray remained untouched for hours. Staff interviews confirmed that the resident was not offered or assisted with her meal due to short staffing and lack of communication among staff. Additionally, this resident was found saturated in urine, with soiled linens and night clothes, and had not been cleansed or repositioned for an extended period, despite being dependent on staff for all ADLs and having a high risk for skin breakdown. Another resident, who was dependent on staff for all ADLs and on hospice care, experienced a failure in receiving assistance with meals. Although staff provided assistance during some meals, there was an incident where the resident's lunch tray was not served, and the meal was not offered until surveyor intervention. Staff interviews revealed a lack of communication regarding meal assistance assignments, resulting in the resident not being fed until the issue was brought to staff attention. The resident had a history of significant weight loss, and her family expressed concerns that she was not always being fed her meals. A third resident, with a history of stroke and hemiplegia, required set-up assistance for personal hygiene and was dependent on staff for bathing. Observations showed that the resident's facial hair was overgrown, fingernails were excessively long with debris underneath, and he had not received assistance with shaving or nail care despite requesting help from staff. The resident reported frustration at being unable to maintain his grooming due to lack of assistance. Staff interviews confirmed that shaving and nail care had not been offered or completed, and unit management was not monitoring the completion of these ADLs.