Failure to Provide Timely Assistance with ADLs and Incontinence Care
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs), including feeding, dressing, and incontinence care, for five residents who were dependent on staff for these needs. Observations showed that several residents remained in the dining room for extended periods without being checked for incontinence, and some were found with soiled briefs or clothing. For example, one resident was left in a soaking wet incontinence brief with a bowel movement, and another was observed with a brown substance on his fingers and pants, later identified as stool, which was not fully cleaned after initial attempts by staff. Residents with significant medical histories, such as dementia, diabetes, mobility impairments, and self-care deficits, were not provided with the necessary assistance in a timely manner. One resident, dependent on staff for eating, was observed eating chili with his hands and drinking from the bowl, while staff were occupied assisting another resident. The resident was only assisted with feeding after several minutes, and incontinence care was delayed for multiple residents, with checks and changes occurring well after the recommended intervals. Interviews with staff and family members confirmed that residents were not being checked for incontinence every two hours as required by facility policy. Family members reported finding residents in bed late in the morning with dirty hands, and staff acknowledged that residents' clothing should be changed if soiled. Facility guidelines specify that feeding and incontinence care should be provided according to individual needs and at least every two hours, but these standards were not consistently met for the residents reviewed.