Failure to Prevent and Investigate Resident Neglect
Penalty
Summary
A resident with multiple medical conditions, including cardiac arrhythmia, heart failure, muscle weakness, and reduced mobility, was dependent on staff for all activities of daily living, including toileting and personal hygiene. The resident was always incontinent of urine and bowel and required two-person assistance for transfers and incontinence care. On the date in question, the resident reported that his call light was not answered in a timely manner, and when a staff member did respond, she turned off the call light without providing the requested incontinence care, stating she would return but did not. The resident had to activate his call light multiple times before eventually receiving care from other staff members, by which time his incontinence brief was saturated and nearly disintegrated. Multiple staff statements corroborated that the agency CNA assigned to the resident's unit repeatedly failed to respond to call lights, turned off call lights without providing care, and spent extended periods away from her assigned duties, including being outside and in the activity room. Other CNAs reported that this staff member neglected not only the resident in question but also other residents on the unit, resulting in unmet care needs and emotional distress. One resident was reportedly dropped during a transfer, and several residents were left without proper nighttime care due to the lack of assistance from the agency CNA. The facility's investigation was incomplete, as it focused solely on the initial resident who reported neglect and did not include interviews or assessments of other potentially affected residents or all staff involved. The LPN on duty was informed of the concerns late in the shift but did not address them with the agency CNA or review the written statements provided by staff. The facility's policy required thorough investigation of all allegations of neglect, including interviewing all involved parties and assessing all potentially affected residents, but these steps were not fully carried out.