Failure to Provide Required ADL Assistance During Toileting
Penalty
Summary
A dependent resident with a history of stroke and language deficits, who was cognitively intact and required two staff for toileting assistance, did not receive the necessary assistance with activities of daily living (ADLs). The resident was admitted with a care plan indicating the need for staff to remain present while on the commode. Despite this, a grievance was filed after the resident was left on the commode for 30 minutes, and the resident specifically requested not to be left alone. The care plan was revised to reflect this preference, and signage was posted in the resident's room instructing staff not to leave the resident alone on the commode. However, staff interviews revealed that the CNA assigned to the resident was unaware of the updated care plan and the requirement to remain with the resident, as the Kardex had not been updated following a recent fall. During a time when the CNA was assisting another resident, other staff were instructed to assist, but the resident still experienced a delay in assistance and reported distress. The facility's investigation into the grievances did not identify the staff involved, and there was an expectation from leadership that the Kardex should have been updated and a thorough investigation conducted.