Failure to Provide Timely ADL Care and Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs), including grooming and personal hygiene, for several residents who were unable to perform these tasks independently. Multiple residents, all of whom were dependent on staff for ADLs due to various medical conditions such as gastroparesis, neuromuscular dysfunction of the bladder, Parkinson's Disease, and dementia, did not receive scheduled showers, timely brief checks, or changes as needed. Family members, hospice staff, and residents themselves reported that staff did not consistently check or change briefs every two hours as required, and that residents sometimes remained in soiled briefs for extended periods. Photographic evidence and direct observations supported these claims, with one resident's brief remaining unchanged for an entire day despite visible soiling and blood. Interviews with staff, including CNAs, nurses, and the DON, revealed that the facility was experiencing significant staffing shortages following the elimination of medication aides and a reduction in CNA numbers. Staff consistently reported that the workload was unmanageable, making it impossible to complete two-hour rounds and provide timely care for all residents. As a result, residents were not being checked or changed as scheduled, and some went weeks without a bath or fresh linens. Staff also noted that the lack of adequate staffing led to delays in responding to call lights and providing water to residents. Documentation review showed that care plans were not always completed or updated in a timely manner, and that grievances had been filed by residents and families regarding missed showers and infrequent brief changes. The facility's infection surveillance report indicated a high number of urinary tract infections over a three-month period, which staff and administration acknowledged could be related to residents being left in soiled briefs. The facility's own policies defined neglect as the failure to provide necessary goods or services to avoid physical harm or emotional distress, and the events described in the report met this definition.