Neglect in Providing Incontinent Care
Penalty
Summary
During an abbreviated survey, it was found that a resident did not receive necessary assistance with activities of daily living, specifically personal hygiene care, during the 11:00 PM-7:00 AM shift. A Certified Nursing Assistant (CNA) failed to provide incontinent care to the resident, who was later observed saturated with urine. The CNA admitted to forgetting to provide care and falsely documented that care was given. Surveillance video confirmed that no care was provided during the shift. The resident involved had a history of hypertension, hyperlipidemia, and age-related muscle weakness, with moderately impaired cognition. The resident required dependent assistance for incontinent care every shift, as documented in their care plan. Despite this, the CNA did not perform the necessary care, leading to the resident being found in a state of neglect. The facility's policies on resident care and neglect were not adhered to, resulting in the termination of the CNA for neglect and falsification of documentation.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #1 On 10/4/23, the resident was immediately provided with ADL care by the assigned CNA for the day shift after it was determined that the resident had not received ADL care on the 11-7 shift. On 02/25/2025 the resident’s ADL self-care deficit care plan and CNA nursing care instructions were reviewed by the Interdisciplinary Team (IDT) to ensure that necessary services to maintain good nutrition, grooming, and personal and oral hygiene were properly addressed. No revisions were needed to the plan of care. The Nurse Manager reviewed the plan of care with the unit staff and the staff’s responsibility to provide ADL care for this resident who requires total assistance with ADL care. CNA #3 was terminated on 10/4/23. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially affected by the same practice. Between 02/25/2025 and 03/25/2025 a full facility audit will be conducted by the IDT members to identify and assess all residents who require assistance with ADLs. This assessment will involve reviewing care plans to ensure that the necessary ADL assistance is clearly identified and outlined for each resident. Any immediate needs will be addressed promptly with staff providing the required care and support. Any revisions to a resident’s ADL plan of care will be reviewed with the responsible unit staff. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Administrator, DNS, and RN/MDS Coordinator will review and revise, as needed, the policy and procedure for Activities of Daily Living (ADL) including staff responsibility to provide ADL care as outlined in the individual plan of care for dependent residents. The DNS/designee will provide additional education to all CNAs regarding their responsibilities in providing ADL care for dependent residents. The education will focus on the importance of providing timely and appropriate assistance with ADLs, understanding and adhering to individual care plans and CNA nursing instructions, and recognizing signs of unmet ADL needs. This training will be incorporated into the orientation of new Nursing staff members and will be reviewed annually and as needed. RN Supervisors will monitor compliance through routine observational rounds to ensure that ADL care is provided consistently and in accordance with each resident’s care plan. Immediate corrective actions, including staff re-education and, if necessary, disciplinary action, will be implemented for any deviations or failure to provide required ADL care. The IDT will be responsible for reviewing and updating each resident’s care plan to ensure it accurately reflects their ADL needs and preferences. Care plans will include specific details regarding the frequency and type of assistance required, as well as any special considerations (e.g., preferred timing or specific requests for assistance). IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with the provision of ADL care per the plan of care. The RN/designee will audit 20% of residents requiring different levels of ADL assistance monthly for the next three months, then quarterly for the following three quarters. Each audit sample will include ADL dependent residents. All audit findings will be reported to the Administrator and DNS monthly. Corrective actions, such as staff reeducation or revision to the plan of care, will be implemented as needed. The DNS/designee will report ADL audit findings to the QA Committee on a quarterly basis for evaluation, discussion, and follow-up corrective action. At the end of the fourth quarter, the QAPI Committee will assess the need for ongoing monitoring and determine the appropriate frequency.