Failure to Provide Assistance with ADLs Due to Staff Neglect
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically related to nutrition, incontinence care, and positioning, for five residents. Clinical records revealed that these residents had significant medical conditions, including progressive neurological disorders, dementia, Parkinson's disease, aphasia, hemiparesis, and spinal stenosis, resulting in high levels of dependency for basic care needs such as eating, oral hygiene, toileting, personal hygiene, and mobility. The Minimum Data Set assessments indicated that these residents required maximal or total assistance from staff for these activities. On the date in question, facility documentation and staff statements confirmed that several residents did not receive required incontinent care, and one resident was found with food in their mouth after the evening meal had ended. Observations included residents being unkempt, soiled, and uncomfortable, with one resident lying flat with food in their mouth unsupervised, another with a bowel movement that had soiled their clothing, and another in bed with their head and feet hanging off opposite sides of the mattress. Two additional residents were found wet and in need of incontinent care that appeared to have been delayed for an extended period. The deficiency was linked to a nurse assistant being observed asleep in a resident room by multiple staff members, resulting in the neglect of care for these residents. Staff interviews confirmed that the nurse assistant had been sleeping during their shift, which directly contributed to the residents not receiving timely and appropriate care as required by their conditions and care plans.