Failure to Provide Timely Assistance with Activities of Daily Living
Penalty
Summary
A resident with a complex medical history, including blunt abdominal trauma, non-displaced C5 and C7 fractures, anxiety, a right upper arm partial thrombus, and a tracheostomy, was admitted to the facility. The resident was left soiled and their activities of daily living were not met in a timely manner. The incident occurred when a registered nurse failed to respond to the resident's call light and did not provide assistance when the resident attempted to communicate her needs. The nurse initially believed the call light was for another patient and, upon realizing it was for this resident, asked her to write down her request when she could not speak clearly. When the resident did not write down her needs, the nurse did not pursue further assistance and continued with other tasks until a respiratory therapist informed him that the resident needed to be changed. Interviews and record reviews confirmed that the nurse did not notify a CNA or provide timely care, resulting in the resident remaining soiled. The facility's policy requires that residents receive good personal hygiene and timely care to prevent bedsores and incontinence. The Director of Nursing acknowledged that there was no justification for the nurse's failure to assist or communicate the resident's needs to other staff. This lapse in care was identified through interviews, record reviews, and direct observation.