Failure to Provide Timely ADL and Incontinence Care Due to Missed Rounds and Inaccessible Call Light
Penalty
Summary
Facility staff failed to provide necessary services for a resident who was unable to carry out activities of daily living (ADLs), as required by both facility policy and the resident's care plan. The resident, a male with severe cognitive impairment and multiple diagnoses including cerebral infarction, epilepsy, ALS, and incontinence, required extensive to total assistance with mobility, hygiene, and toileting. The care plan specified that two staff members were needed for assistance, frequent rounding was required to anticipate needs, and incontinent care was to be performed every two hours. Despite these requirements, interviews and observations revealed that staff did not consistently perform two-hour rounds or ensure the resident's call light was within reach. The resident and his roommate reported that staff often failed to respond to call lights, sometimes turned off the call light without addressing needs, and left the resident in soiled briefs for extended periods. The roommate frequently had to use his own call light or seek staff assistance in the hallway. Observations confirmed that staff were sometimes seated in the hallway using their cell phones instead of attending to residents' needs, and the resident was unable to reach his call light when assistance was needed. Staff interviews indicated a lack of consistent adherence to rounding schedules and responsibilities. While some CNAs described their routines, there was confusion about assignments and a lack of follow-through in ensuring call lights were accessible and needs were met. Facility in-service records confirmed that staff were trained to perform rounds and incontinent care every two hours and to keep call lights within reach, but these practices were not consistently implemented for this resident.