Failure to Provide and Document Assistance with ADLs for Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADL) for a dependent resident who was unable to get out of bed independently. On two consecutive days, the resident was observed lying in bed in a night gown, expressing a desire to get out of bed but stating that staff would not assist and that he did not know the location of his wheelchair. Interviews with staff revealed conflicting accounts, with some stating the resident usually refuses to get up, while others confirmed the resident should be assisted unless he refuses. The resident was documented as cognitively intact and having poor trunk control and weakness on one side, requiring a Geri chair for mobility, which was found stored near his room. Review of the resident's records, including progress notes and the plan of care, showed no documentation of refusals to get out of bed or education provided regarding the importance of mobility, despite staff stating that such documentation is required when a resident refuses care. Additionally, the facility did not provide any policies specific to the importance of getting residents out of bed. These actions and omissions resulted in a failure to ensure that dependent residents received appropriate ADL care and assistance as required.