Resident Neglected and Left Unattended, Resulting in Injury and Distress
Penalty
Summary
Facility staff failed to provide necessary ADL care to a resident residing on the special care unit, resulting in the resident being left unattended in bed for an extended period. The resident was found lying on his side at the foot of the bed, with his left arm caught between the mattress and footboard, and was observed to be in significant pain and distress, screaming and crying. The resident was covered in bowel movement, as were the bed, floor, and floor mats, and had sustained skin tears and bruising to his left hand, wrist, and hip, with a large dark-colored mark and indentation likely from pressure. The bed was noted to be elevated except at the foot, and the resident was combative during care, resisting staff assistance. Review of staff witness statements and personnel files revealed that the CNAs assigned to the resident did not provide care from approximately 2:00 a.m. to 7:00 a.m., despite being aware of the resident's needs and distress. One CNA reported not feeling comfortable with the resident due to his behavior and did not inform the nurse of the situation, while the other CNA did not perform any cares during this period. Both CNAs were subsequently terminated for neglect. Facility policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or emotional distress, and includes recurrent failure to provide incontinence care.