Failure to Provide ADL Assistance and Voiding Pattern Assessment per Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide activities of daily living (ADL) assistance and to assess and follow voiding patterns as outlined in the resident’s care plan. Resident 3, admitted in early February and readmitted from the hospital later that month, had diagnoses including metabolic encephalopathy, repeated falls, and muscle weakness, and a BIMS score of 9 indicating moderate cognitive impairment. The resident’s MDS documented a need for setup/clean-up assistance with eating and upper body dressing, supervision with oral hygiene, and partial/moderate assistance with bathing, lower body dressing, footwear, toileting, bed mobility, and transfers. The care plan specified one-person partial assistance with ambulation using a walker, bed mobility, transfers, toileting hygiene, and supervision with toilet transfers. The resident was occasionally incontinent of bladder, frequently incontinent of bowel, on a diuretic, and care plan interventions included establishing voiding patterns and using disposable briefs changed as needed. Despite these documented needs, the facility did not complete a voiding patterns assessment for the resident, and staff did not follow the planned assistance and monitoring. Progress notes showed multiple falls over two days, including unwitnessed falls where the resident was found on the floor next to the bed and a witnessed fall where staff saw the resident sliding out of bed. On the morning of the survey observation, staff did not enter the resident’s room to check or change the resident between 4:30 a.m. and 8:55 a.m., except when a nursing assistant briefly delivered a breakfast tray without assessing needs. Later, an LPN observed the resident independently getting out of bed, ambulating with a walker to the bathroom, and transferring on and off the toilet without offering assistance or supervision, despite the care plan and MDS indicating the need for partial/moderate assistance and supervised toilet transfers. The resident’s spouse was observed changing the bed and picking up the room, stating that staff “don’t do anything” and noting dried blood on the bedding. The NA and DON both confirmed residents were supposed to be checked every two hours, that this had not occurred, that no voiding pattern assessment had been completed, and that staff should have assisted and supervised the resident with transfers and toileting as care planned.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.