Failure to Provide Timely ADL Assistance Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide timely staff assistance with activities of daily living (ADLs) for five dependent residents, as evidenced by record reviews, call light audit reports, and resident and staff interviews. Several residents with significant medical conditions, including acute kidney failure, Parkinson's disease, multiple sclerosis, and mobility impairments, required substantial or maximal assistance with toileting, bathing, and other ADLs. Documentation showed that call lights for assistance remained unanswered for extended periods, with one resident's call light active for over 52 minutes and another for over 36 minutes before staff responded. Residents reported having to wait for long periods, sometimes resulting in incontinence episodes and missed showers or baths, which caused them distress and humiliation. On the date in question, only one CNA was available to provide care for all residents during a specific time frame, despite several residents requiring two-person assistance. The CNA confirmed being unable to answer most call lights in a timely manner and was unable to provide scheduled showers or baths. The Director of Nursing acknowledged that the lack of adequate CNA staffing led to delays in providing necessary ADL assistance to multiple residents. Residents also reported a decline in the timeliness of staff response and the frequency of receiving scheduled showers compared to previous months. Care plans and medical records for the affected residents indicated a need for regular assistance with toileting, bathing, and skin assessments due to their medical conditions and risk factors such as incontinence and decreased mobility. However, documentation and resident interviews confirmed that these interventions were not consistently provided as scheduled, particularly on the day when staffing was insufficient. The deficiency was substantiated by both resident accounts and facility records, demonstrating a failure to meet the residents' needs for timely ADL support.