Failure to Provide Timely and Appropriate ADL, Skin, and Oral Care for Dependent Residents
Penalty
Summary
The facility failed to provide appropriate care and services to three residents who were dependent on staff for activities of daily living (ADL), including incontinence care, skin care, and oral hygiene. One resident with multiple diagnoses, including respiratory failure, stroke, and reduced mobility, was observed to have her call light activated for over 20 minutes before staff responded to provide incontinence care. Staff interviews confirmed that call lights were not always answered within the expected timeframe due to staffing constraints, and the resident herself reported sometimes waiting up to three hours for incontinence care. Another resident, admitted with chronic respiratory failure, diabetes, and morbid obesity, was dependent on staff for all ADLs and had a history of skin issues. During a temporary relocation due to a water leak, this resident and two others were not provided with timely incontinence care, resulting in prolonged exposure to soiled conditions. Observations revealed the resident had very dry, peeling skin on her feet, a bleeding open area on her buttock, and was not offered lotion or oral care during routine care. Staff interviews indicated that aides did not consistently apply prescribed creams or offer mouth care, and there was a lack of documentation regarding the open wound. A third resident with severe cognitive impairment and hemiplegia was also dependent on staff for most ADLs. During care, this resident was found to have very dry, flaky skin on the lower legs and feet, and red buttocks, but no lotion or mouth care was provided or offered. Staff confirmed that lotion was typically only applied on shower days and mouth care was not routinely performed. Facility policies required that lotion or cream be offered during care and that mouth care be provided, but these were not followed. The DON confirmed that staff should have offered these services according to policy.