Failure to Prevent Neglect and Ensure Timely Care for Resident
Penalty
Summary
The facility failed to administer care in a manner that enabled effective and efficient use of its resources to maintain the highest practicable well-being of a resident. The administrator did not ensure that staff refrained from willful abuse and neglect, as evidenced by staff not assisting a resident out of bed at a reasonable time, causing her to miss breakfast and lunch on a regular basis. The resident was consistently left in bed for most of the day, despite care plans and interdisciplinary team agreements specifying she should be up in her wheelchair between 6:00 AM and 7:30 AM daily to eat meals and reduce her risk for aspiration pneumonia. The resident, an elderly female with rheumatoid arthritis, dysphagia, acquired neck deformity, 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. Multiple records, including care plans, progress notes, and video evidence, showed repeated instances where she was not assisted out of bed until the afternoon, resulting in missed meals and prolonged periods in soiled linens. Staff interviews confirmed that some aides refused to enter her room due to personal conflicts or perceptions of her being a difficult resident, and this refusal was tolerated by facility leadership. The resident experienced significant weight loss over several months, and both she and her family reported feelings of neglect and lack of dignity. Observations and interviews with staff, the resident, and her family revealed a pattern of neglect, with staff failing to follow the care plan and not providing timely assistance. Staff acknowledged that the resident was often not gotten up before breakfast, and some admitted to avoiding her room. Leadership interviews indicated awareness of the issue, with the administrator and others noting that staff were allowed to refuse care assignments. The facility's own policies required prevention and identification of neglect, but these were not followed, resulting in the resident missing meals, remaining in bed for extended periods, and experiencing psychosocial and physical harm.
Removal Plan
- Regional Director of Operations in serviced Administrator on Abuse/Neglect.
- Regional Director of Operations and Director of Clinical Services will attend EMR meetings to ensure any resident issues identified have appropriate interventions.
- Administrator in-serviced all team members on compliance 24-hour hot line where team members can report any concerns and or if administration is not taking corrective action or putting interventions in place to ensure residents are being cared for by staff appropriately.
- Compliance hotline notifications will be posted by time clock and breakrooms.
- Administrator trained by Regional Director of Operations.