Failure to Provide Timely ADL Care Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide timely Activities of Daily Living (ADL) care to residents who were dependent on staff assistance. Multiple residents reported and were observed experiencing significant delays in receiving incontinence care and assistance with hygiene, despite having care plans indicating their dependence on staff for these needs. For example, one resident with a urinary tract infection (UTI) remained soiled for over 45 minutes while her call light went unanswered, and only received assistance after external intervention. Another resident described waiting over two hours to be changed, and others reported similar prolonged waits for care, often attributing these delays to chronic understaffing. Residents interviewed consistently described a pattern of inadequate staffing, with only one or two nurse aides available for the entire building at times, and reliance on staff working extended shifts or calling in off-duty personnel to provide basic care. Several residents expressed distress and frustration over the lack of timely assistance, with one resident stating that she had to wait for hours to be changed and another reporting that her call light was repeatedly turned off without her needs being met. Observations by surveyors confirmed that call lights were left unanswered for extended periods, and residents were left in soiled clothing or with emesis on their clothing without prompt help. Record reviews corroborated that the affected residents had care plans requiring substantial or maximal assistance with toileting, hygiene, bed mobility, dressing, and bathing due to chronic health conditions, impaired mobility, and cognitive impairment. Despite these documented needs, the facility did not ensure that staff were available or responsive enough to meet residents' ADL requirements in a timely manner, resulting in prolonged periods where residents remained soiled or unassisted.