Resident Left Unattended in Soiled Brief Due to Staff Neglect
Penalty
Summary
A resident with quadriplegia, depression, anxiety disorder, and chronic pain, who was totally dependent on staff for all activities of daily living, was left unattended in a soiled brief for an extended period. The resident was last changed at approximately 10:30 PM by the evening shift GNA and was not changed again until 8:00 AM the following morning, despite ringing the call bell several times during the night. The night shift GNA entered the room, turned off the call bell, but did not provide care. Both GNAs assigned to the unit that night reported not answering any call bells or providing care to the resident during their shift. When the morning staff arrived, the resident was found visibly upset, crying, and lying in a bed soaked with urine. The resident was alert and oriented, with a BIMS score of 15, and clearly communicated the lack of care received overnight. Staff interviews confirmed that the resident did not receive the required care and that there was a history of issues with night shift aides not performing their duties. The facility's documentation and witness statements corroborated the resident's account of neglect.