Failure to Provide Timely ADL and Incontinent Care
Penalty
Summary
Two residents were not provided with necessary assistance for activities of daily living (ADLs), specifically related to personal hygiene and timely incontinent care. One resident, who had diagnoses including macular degeneration, congestive heart failure, and diabetes, was admitted to the facility and did not receive any bathing or morning care for several days after admission. The resident reported feeling unclean and uncomfortable, and observations confirmed the absence of personal hygiene supplies in the room, as well as visible signs of poor hygiene such as dry, flaking skin on bedsheets. Staff interviews revealed that morning care was not provided daily as required, and that personal care items should have been present upon admission but were not. Another resident, with a history of hemiplegia, hemiparesis, and amputation, was dependent on staff for toileting and hygiene. This resident reported requesting incontinent care over an hour prior to being assisted, and repeated requests for care were not promptly addressed. Observations showed that the resident's call bell remained unanswered for an extended period, and staff acknowledged that care was delayed due to workload and the need for two staff members to assist. Staff interviews confirmed that timely incontinent care was not provided, despite the resident's dependency and the importance of preventing skin breakdown. Facility policies required daily assistance with ADLs, including bathing, grooming, and toileting, to maintain residents' dignity, skin integrity, and overall well-being. However, the documented actions and inactions of staff resulted in residents not receiving the necessary care as outlined in facility procedures and policies. Staff and supervisory interviews consistently indicated that the care provided did not meet the expected standards for daily hygiene and timely response to resident needs.