Failure to Provide Timely ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including transfer, toileting, and dressing, to residents who were dependent on staff. Multiple residents with significant physical and cognitive impairments were observed or reported to have waited extended periods for staff assistance, resulting in prolonged exposure to soiled incontinence briefs, missed transfers, and unmet hygiene needs. For example, one resident with dementia, legal blindness, and incontinence was found in the dining room wearing a soiled gown and sitting in a wheelchair with a wet blanket, emitting a strong odor of urine. Family and staff confirmed that the resident had not been changed for several hours, and the assigned CNA did not return to assist after being notified. Another resident with paraplegia and dependent on a mechanical lift for transfers reported that her call light was on for hours without response, and staff were observed turning off her call light without providing the requested assistance. Staff interviews revealed confusion about resident assignments, especially when CNAs arrived late for their shifts, resulting in residents not receiving timely care. Several staff members, including CNAs and LPNs, were unaware of which residents required coverage or assistance during shift changes, leading to further delays in care. Additional residents with conditions such as chronic pain, hemiplegia, and severe cognitive impairment also reported or were observed experiencing significant delays in receiving incontinence care, transfers, and hygiene assistance. Residents described waiting several hours for help, being left in soiled briefs, and having to seek assistance multiple times without response. Resident council meeting minutes and facility concern forms documented ongoing concerns about staff availability and delayed call light response times, further corroborating the pattern of unmet ADL needs among dependent residents.