Failure to Prevent Resident Neglect in Meal Assistance and Toileting
Penalty
Summary
The facility failed to protect two residents from neglect, as evidenced by a review of facility policy, documentation, and interviews. For one resident with chronic pain, hemiplegia, and weakness, the care plan and Kardex indicated a need for assistance with meals and feeding. Despite these documented needs, staff did not enter the resident's room during the lunch period, did not offer the meal tray, and did not assist with dentures, leaving the resident unable to eat. The resident confirmed that assistance was not provided, and staff interviews corroborated that the required help was not given. Another resident with depression, anxiety, and diabetes, who was cognitively intact, reported frequent delays in toileting assistance. The resident stated that staff were insufficient, resulting in prolonged waits to be placed on a bedpan, leading to episodes of incontinence and remaining in soiled briefs for extended periods. Documentation showed significant gaps between toileting times, sometimes exceeding ten hours, and a lack of evidence that the resident was toileted during certain night shifts. The resident also reported being left in the dayroom for long periods, further contributing to episodes of incontinence. Interviews with staff, including the Assistant Director of Nursing and the Nursing Home Administrator, confirmed that the facility did not provide the necessary care and assistance to prevent neglect for these two residents. The findings were based on direct observations, resident and staff interviews, and a review of clinical records and facility documentation.