Failure to Prevent Resident Neglect Due to Lack of Night Shift Care and Documentation
Penalty
Summary
A deficiency occurred when a resident's right to be free from neglect was not upheld, as the facility failed to ensure the resident received necessary care during the night shift. The resident, who had diagnoses including overactive bladder and required partial assistance for mobility and toileting, reported that he called for help throughout the night but did not receive assistance. Upon morning shift change, staff found the resident with a full urinal, wet bed, and soiled brief, confirming that his care needs had not been met during the previous shift. Interviews with staff revealed inconsistencies in the accounts of care provided. Some CNAs and nurses stated that the resident was checked and attended to multiple times during the night, while others acknowledged that it was not uncommon to find residents with overflowing urinals and soaked beds at the start of the morning shift. The resident himself reported frequent issues with the night shift not responding to call lights, and described an incident where a nurse entered his room, turned off the call light, and left without providing care, despite his bed being soaked. A review of the clinical record and facility documentation showed a lack of evidence that care was provided or that the resident refused care during the night in question. The facility's own investigation verified the allegation of neglect, noting that there was insufficient documentation to disprove the resident's claim. The Director of Nursing confirmed the absence of documentation for care provided to the resident on multiple shifts, and staff interviews indicated that there was no clear policy for documenting such care.