Resident Left on Soiled Bedpan Due to Staff Communication Breakdown
Penalty
Summary
A resident admitted for surgery aftercare following a right lower leg fracture, with a history of falls and difficulty walking, was left on a soiled bedpan for hours during the night without any response to multiple call light activations. The resident reported feeling helpless and embarrassed by the experience and notified a nurse the following morning. Staff interviews confirmed that the resident was left unattended due to a communication breakdown between two CNAs who changed assignments mid-shift, resulting in the resident's needs being overlooked. Facility staff, including a CNA, a licensed nurse, and the DON, acknowledged that the standard procedure is to respond promptly to call lights and not to leave residents on bedpans for extended periods, as this can cause discomfort and potential skin breakdown. Review of facility policies confirmed that residents should be treated with dignity and respect, with prompt toileting assistance and removal from bedpans as soon as they indicate they are finished. The failure to follow these procedures led to the resident enduring an undignified and uncomfortable situation.
Plan Of Correction
F550 How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: DSD/ADSD/Nursing Supervisor In serviced 6/5/25. CNAs on 5/28/25 and 6/5/25 offering and removal of bedpans that emphasize dignity and respect for the residents during this process. One resident was affected by deficient practice. Follow-up interviews with the affected resident confirm that there have been no recurrences of deficient practice and deny any residual emotional effects. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: DON/MDS/Nursing Supervisor identified residents who utilize bedpans. Three (3) residents have the potential to be affected by deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Therapy will track new admissions who utilize bedpans, communicate identified residents to Nursing. Identified residents who utilize bedpans will be updated in their toileting care plan. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system and includes dates when corrective action will be completed. The corrective action dates must be acceptable to the State Agency. Department heads/Interdisciplinary Team will identify resident concerns through daily Angel rounds, via review of monthly Resident Council minutes, and during quarterly care conferences. Findings will be reviewed in QAPI for three months.