Neglect in Incontinence Care for a Resident
Penalty
Summary
Norriton Square was found to be non-compliant with the requirement to ensure residents are free from neglect, as outlined in 42 CFR Part 483.12(a)(1). The deficiency was identified during an abbreviated survey following complaints, where it was determined that a resident, identified as R12, did not receive adequate incontinence care. The facility's policy on abuse and neglect, which prohibits mistreatment and mandates effective communication and training, was not adhered to in this instance. The resident, who had severe cognitive impairment and was dependent on staff for toileting hygiene due to a left hip fracture, was found soiled with urine, and their wound dressing was also soiled. This neglect was attributed to a nursing assistant, Employee E3, who admitted to overlooking the resident due to being overwhelmed with the care of eighteen patients. Resident R12 had a complex medical history, including a non-displaced intertrochanteric fracture of the left femur, chronic embolism and thrombosis of the vein, diabetes with neuropathy, and a personal history of transient ischemic attack. The resident's care plan highlighted the need for regular monitoring for skin irritation and repositioning every two hours to prevent skin breakdown, as the resident had a stage three pressure ulcer on the sacrum. Despite these documented needs, the facility failed to provide the necessary care, resulting in the substantiated report of neglect. The nursing home administrator confirmed the neglect after an investigation and noted that Employee E3 had prior disciplinary actions related to care concerns.
Plan Of Correction
1. R12 has discharged from the facility. 2. NPE or designee will re-educate staff on OPS300 Abuse Prohibition policy with review of the definition of Neglect. 3. The Director of Nursing or designee will conduct an initial audit of incontinent residents to ensure incontinence care was provided. 4. The Director of Nursing or designee will conduct random weekly audits x 12 weeks of 10 incontinent residents to ensure incontinence care was provided. 5. NHA or designee to review the results of these audits will be reviewed at the monthly QAPI meeting x 3 months.