Failure to Provide and Document Required ADL Assistance for Feeding and Toileting
Penalty
Summary
The facility failed to provide and document required Activities of Daily Living (ADL) assistance, including feeding and toileting, for three residents. Facility policy dated 7/15/25 required staff to provide appropriate treatment and services to maintain or improve residents’ ability to perform ADLs, including toileting and feeding, and to document all ADL support in the electronic health record, including proper positioning for eating and maintaining an elimination schedule. One resident (CR1), admitted with heart failure, stroke, and diabetes mellitus, had hospice documentation and progress notes indicating a need for complete assistance with all ADLs, including feeding, and staff assistance with all aspects of care due to worsening fine motor function and difficulty feeding self. However, from 10/28/25 to 12/21/26 there was no physician order to assist with feeding, and documentation for multiple dates in December showed the resident was not provided help or staff oversight while eating, with no recorded percentages of food or fluid intake. The same resident’s documentation also lacked evidence of assistance with toileting for 18 shifts in December. Another resident (R2), admitted with heart failure, hypertension, and malnutrition, reported sometimes waiting a while for toileting assistance. Documentation for this resident showed no evidence of toileting assistance for six shifts in December. A third resident (R3), admitted with dementia, malnutrition, adult failure to thrive, and dysphagia, had a physician order for a pureed, thin-consistency diet with instructions for upright posture, slow rate, small bites/sips, and set-up and feeding from staff as needed, and a care plan directing staff to assist to an upright position for all meals, set up and assist with eating as needed, and monitor and document dysphagia symptoms. An undated facility list identified this resident as needing assistance with meals. During observation, a nurse aide set up the meal tray and left the room, and the resident was seen eating rapidly in bed without being in an upright position and without staff assistance. A registered nurse confirmed the resident was not upright and was not being assisted with meals. Staff interviews, including with a nurse aide and the DON, confirmed that staff are required to document feeding and toileting each shift and that the facility failed to document that ADL care was provided for the three residents.
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.