Failure to Meet Professional Standards of Care and Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure that care provided to two residents met professional standards of practice. For one resident, after an unwitnessed fall resulting in a forehead laceration and a left wrist fracture, there was no documented evidence of follow-up nursing care. The resident's medical record lacked documentation of neurological checks for the head injury, circulation checks for the fractured arm, and progress notes regarding the resident's condition following the fall and injuries. The Director of Nursing confirmed the absence of this required documentation during the surveyor's review. In a separate incident, another resident was observed unattended, lying naked in a high bed, calling for help, and holding onto the bed rail. A soiled disposable brief was found on the floor, and a feces-soiled washcloth was left in the bathroom sink with water running. The privacy curtain was not drawn, and no staff were present in the room for at least ten minutes. The assigned GNA later stated that the resident had refused care and become combative, so the GNA left the resident in that condition. The Unit Manager and Regional Clinical Services Director subsequently provided education to the GNA regarding safety, privacy, dignity, infection control, and handling of residents who refuse care.