Failure to Provide Proper Shift Report Results in Resident Left Soiled and Exposed
Penalty
Summary
The facility failed to ensure proper hand-off or shift report between nursing staff, resulting in a resident being left undressed and covered in feces. During an observation, the resident was found lying in bed, exposed from the hallway, with feces on her body, sheets, and the floor. The resident was dependent on staff for all activities of daily living, including toileting, bathing, dressing, and personal hygiene, and had severe cognitive impairment, as documented in her medical records. The care plan required frequent assistance, keeping the resident clean and dry, and dressing her appropriately. A newly hired CNA assigned to the resident reported not receiving any hand-off or shift report from the charge nurse regarding the resident's behaviors, such as removing her diaper and undressing herself. The CNA stated he had not been trained on caring for residents with such needs and was told by the charge nurse to delay care until after his lunch break, despite the resident's agitation and refusal of care earlier. Facility leadership acknowledged that hand-off reporting was not included in CNA orientation and that communication between charge nurses and CNAs was lacking, especially for new and registry staff. The facility's policy required shift reporting to ensure continuity of care, but this was not followed in this instance.