Failure to Provide Timely ADL Assistance and Incontinence Care
Penalty
Summary
Facility staff failed to provide necessary activities of daily living (ADL) assistance, specifically incontinence care and repositioning, to a resident who was completely dependent on staff for these needs. The resident, who had significant medical conditions including intracerebral hemorrhage, hemiplegia, aphasia, chronic respiratory failure, and was always incontinent, was observed in bed for at least five continuous hours without staff checking for incontinence or repositioning. During this period, only brief interactions occurred for medication administration and tube feeding, with no ADL care provided. When staff eventually entered the room to provide care, the resident was found with a wet brief containing a small bowel movement and a newly observed pink area on the sacral region, which had not been present two days prior. Interviews with staff and the DON confirmed that the facility's expectation was to check dependent residents for incontinence and repositioning at least every two to four hours, and the observed lapse exceeded this standard. The documentation reviewed did not specify required frequency for incontinence care, and no additional information was provided by facility leadership regarding the incident.