Resident Left Unclothed and Exposed Due to Incomplete Care by Inexperienced NA
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and moderately impaired cognition was left in bed unclothed, with his genitals exposed, after an agency nursing assistant (NA) failed to complete his morning care. The resident, who required assistance with dressing and personal hygiene due to his medical condition, reported that the NA was unfamiliar, lacked a name tag, and appeared unsure of the care routine. The NA began cleaning the resident but then left the room, instructing the resident to find someone else to finish the care. The resident called out to another NA, who found him exposed and immediately covered him before completing his care. The second NA reported the incident to an LPN, but the LPN did not escalate the issue to nursing leadership. The director of nursing (DON) only became aware of the incident two days later through staff communication. The NA responsible for leaving the resident exposed was a new employee who had recently completed orientation and training on resident dignity and personal care. The facility's policy required prompt notification and protection of resident rights, but the incident was not reported in a timely manner, and the resident's dignity was not maintained during care.