Failure to Provide Timely ADL and Incontinence Care Due to Inadequate Staffing
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely provision of activities of daily living (ADL) care, including toileting and incontinence care, for multiple dependent residents. An anonymous complaint alleged short staffing, residents remaining in wet or soiled briefs for extended periods, and staff sleeping on the night shift, resulting in neglect of basic care needs. CNAs reported that when only two aides were scheduled instead of three on a floor of about 40 residents, they were unable to provide needed care, including timely feeding and two-hour check-and-change incontinence care, particularly on the midnight shift. Facility schedules showed multiple midnight shifts with only two aides assigned per floor despite a census in the 80s and 22 residents requiring lift assistance. Several residents described prolonged waits for assistance with toileting, incontinence care, and other basic needs. One bedbound, fully dependent resident reported that call lights often took up to two hours to be answered, that staff sometimes turned off the call light and said they would return but did not, and that some aides told them they went to the bathroom too often or were not “wet enough” to be changed despite the resident being on Lasix. This resident recounted an incident where a midnight aide performed inadequate perineal care, leaving stool that became hard and caked on by morning, which made the resident feel awful. Another bedbound, fully dependent resident reported waiting 1–2 hours after activating the call light to be changed, which caused frustration. Two alert, oriented residents who used manual wheelchairs reported frequently waiting about an hour or longer in bed for help with transfers, toileting, water, and medication, including an instance of waiting about an hour and a half for tray pickup and ice, and over an hour for an anxiolytic medication. Another resident’s family member reported repeatedly finding the resident “soaked” in urine during visits, including on the morning of the survey, and the resident nonverbally confirmed distress about being wet. These accounts, combined with staff interviews and staffing records, demonstrated that residents’ ADL and incontinence care needs were not being met in a timely manner, contrary to the facility’s written staffing policy stating that adequate staff would be maintained on each shift to meet residents’ needs and services.
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