Failure to Protect Resident from Neglect and Missed Care
Penalty
Summary
The facility failed to ensure that a resident was protected from psychosocial abuse and neglect, as evidenced by repeated failures to assist her out of bed at a reasonable time, resulting in her missing breakfast and lunch and remaining in a soiled brief for extended periods. The resident, who had diagnoses including rheumatoid arthritis, dysphagia, acquired deformity of the neck, and adult failure to thrive, was dependent on staff for transfers and required to be in her wheelchair to feed herself due to physical limitations. Her care plan specifically directed staff to get her out of bed between 6:00 AM and 7:30 AM daily and to ensure she was up for all meals, but this was not consistently followed. Multiple observations, interviews, and record reviews revealed that the resident was often left in bed until the afternoon, missing meals and personal care. Video evidence and staff interviews confirmed that on several occasions, she was not assisted out of bed until after 1:00 PM, and her call light was left unanswered for hours while she remained in soiled conditions. Staff acknowledged that some aides refused to enter her room due to perceptions of her being a 'difficult' resident, and this led to her care needs being neglected. The resident herself reported feeling hungry, neglected, and tired of being left in her own waste, and her family members corroborated these accounts, stating that the neglect was ongoing and not limited to isolated incidents. Documentation showed a significant weight loss over several months, and staff interviews confirmed that the resident's care plan was not being followed after an initial period of compliance. Staff also admitted to avoiding her room and not providing timely assistance, with some stating they would not go in due to previous accusations made by the resident. The administration was aware that staff were refusing to care for her and that she was missing meals and personal care, but failed to ensure consistent adherence to her care plan and basic care standards.
Removal Plan
- Facility team members were in serviced on Abuse/Neglect for all team members including new hires, PRN, vacation, Agency and Leave of Absence. Education will be provided through verbal in servicing and post-test will be given to ensure retention of education. DON/ADON were provided training on Abuse/Neglect by RDO/RDCS.
- Skin assessment was completed on Resident #1. Skilled Wound Care Physician will conduct an onsite visit.
- Interviewable residents were interviewed by IDT team to inquire if residents had any concerns with any basic care not being met.
- Weight loss summary report was reviewed for all significant weight losses for those residents who are not able to be interviewed to validate that residents who need assistance with meals did not sustain weight loss due to lack of required assistance with meal service and review meal intake documentation.
- Clinical team was in serviced on importance of Q2 hour rounding on residents requiring assistance to ensure their needs are being met.
- One on one education completed with CNA C regarding assisting residents or finding assistance to provide care for residents in need. All staff assigned to resident hall were in serviced that they cannot refuse to go into resident room as assigned. Administrator trained by Regional Director of Operations.
- Daily rounding will be conducted by the IDT team for all assigned residents to address any concerns and identify any issues for those residents unable to communicate.
- Ad HOC QAPI meeting with MD conducted to discuss the plan of correction for compliance.