Failure to Provide Appropriate ADL Care and Behavioral Management
Penalty
Summary
The facility failed to provide appropriate care and services to two residents who required assistance with activities of daily living (ADLs). For one resident with hemiplegia, arthritis, and a pressure ulcer, the clinical record and staff interviews revealed that the resident was totally dependent on staff for bed mobility and transfers. During a dressing change, the resident was positioned near the edge of the bed and slid off onto the floor. Documentation indicated that only one staff member was present during the procedure, despite the resident's care plan and assessment indicating total dependence, which would require two staff members to safely provide care and maintain the resident's position. The facility's post-fall documentation was incomplete, failing to note whether side rails were in place or if current interventions were followed. Another resident with a history of subdural hemorrhage and dementia exhibited new behavioral disturbances, including confusion, agitation, yelling, grabbing staff, and attempting to leave the facility. Despite these changes, the clinical record did not document that the physician or an alternate provider was notified of the resident's altered behavior, which was not typical for this individual. The resident subsequently fell, sustaining injuries that required hospital evaluation. The facility's documentation and care planning did not reflect the new behavioral symptoms or appropriate interventions in response to the resident's condition. Interviews with facility leadership confirmed that the facility did not provide the necessary treatment and services related to ADLs for these two residents. The deficiencies were identified through review of facility documents, clinical records, and staff interviews, and were cited under 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.