F0677

E

Failure to Assist Dependent Residents With ADLs, Positioning, and Eating

Bremerton, Washington Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), including positioning, eating, toileting, and hygiene, for residents who were unable to perform these tasks independently. Facility policy required staff to provide appropriate care and services for residents needing help with hygiene, mobility, toileting, and dining, and to identify underlying causes when cognitively impaired residents resisted care rather than assuming refusal. Despite this, observations, interviews, and record reviews showed that residents with significant physical and cognitive impairments were left without needed assistance, with call lights and essential items out of reach, and with incontinence and positioning needs unmet.

One resident with depression, anorexia, stroke, hemiparesis, moderate cognitive impairment, and risk for malnutrition required substantial to maximal assistance for bed mobility, personal hygiene, dressing, and was dependent for toileting, with frequent incontinence. The Kardex directed that water and needed items, including the call light, be kept within reach, that the resident receive supervision and encouragement with eating, and that staff report refusals of food or fluids to the nurse. During a continuous observation period, the resident was found in bed in a room with a strong urine odor, with an untouched breakfast tray and water out of reach, and the call light pinned behind the head of the bed. The resident reported not having water or food for days and being unable to move their arms. Multiple staff, including a Resident Care Manager, CNAs, an LPN, and a physician, entered the room over the course of nearly two hours, acknowledged the resident’s requests for food, water, and assistance, and noted the urine odor, but assistance with eating and incontinence care was delayed. Water was repeatedly placed out of reach, the lunch tray was delivered and left without timely feeding assistance despite the resident’s repeated statements that they could not move their arms, and incontinent care and repositioning were not provided during the observation.

Another resident with severe cognitive impairment, rib and pelvic fractures, and care plans indicating total dependence for bed mobility and transfers and pain related to multiple fractures was repeatedly observed lying in bed with the head of the bed elevated to 90 degrees, having slid down so that their back was unsupported by the mattress. The resident’s legs were moving, their facial expression was a grimace, and they were whining softly, while dressed in a gown with their brief exposed and visible from the hallway. Over multiple observations, staff walked by the room, glanced in, but did not enter to reposition or cover the resident. An occupational therapist later confirmed the resident was not positioned correctly, appeared uncomfortable and in pain, and noted that this position would be painful given the pelvic fractures. A CNA assigned to the resident stated they had repositioned the resident by ensuring the legs were straight and not hanging off the bed and reported that blankets had covered the resident, which conflicted with the observed condition. The Assistant DON stated an expectation that staff correctly position residents in bed and that all staff assist when they observe a resident in an uncomfortable position, which did not occur in this case.