Failure to Prevent Neglect and Provide Basic Care
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident was free from neglect, as evidenced by multiple observations and record reviews. The resident, who had diagnoses including cerebral infarction, COPD, and GERD, was care planned for interventions such as keeping the head of the bed elevated, use of a low air loss mattress, peri care after incontinence, and heel protectors. The resident was dependent on staff for most activities of daily living, including bed mobility, hygiene, and toileting, and was always incontinent of bowel and bladder. On the day of the incident, the resident was observed repeatedly calling for help, with the call light activated but not making a sound. Staff were present in the hallway but did not respond to the resident's calls. Upon entering the room, the resident was found lying on a mostly deflated mattress with his head and shoulders lower than his body, wearing only a t-shirt and brief, with no pants, blanket, or sheet. The bed linens, bed pad, and dressing on the resident's contracted foot were saturated with urine, and a strong odor was present. The resident's hair was unkempt, facial hair untrimmed, skin dry and flaky, and fingernails long and dirty. Heel protectors were not in place as ordered. Staff confirmed the resident had been in this condition since the start of the shift, and that wounds on the sacral area and gluteal fold were present and had not been treated or assessed by a nurse, despite being reported. Further review revealed that the resident developed new, non-blanchable wounds on the sacrum and left gluteal fold, which were not covered by any current treatment orders. Facility policies required staff to provide necessary services for hygiene and to prevent neglect, defined as failure to provide goods and services necessary to avoid physical harm or emotional distress. The observed inaction and lack of response to the resident's needs, as well as failure to follow care plans and physician orders, led to the finding of neglect.