Failure to Provide Supervision and Care Resulting in Resident Neglect
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral vascular accident, seizure disorder, schizophrenia, severe cognitive impairment, wandering behaviors, and incontinence was not provided with appropriate supervision and care over two scheduled shifts. The resident required partial to moderate assistance with activities of daily living, supervision for mobility, and was at risk for elopement and seizures, as documented in the care plan. The care plan also specified interventions such as encouraging fluids, assisting with toileting, monitoring behaviors, and ensuring staff awareness of elopement risk. On the days in question, a certified nursing assistant (CNA) was assigned to the resident's room but was unaware that the resident occupied the assigned bed. The CNA stated that she believed the bed was unoccupied and had not provided care to the resident, despite facility documentation and the midnight census confirming the resident's assignment to that room and bed. The CNA was new to the floor but had previously been assigned to the same room. Observations revealed the resident's bed was in poor condition, with no sheets, a torn mattress, and evidence of bug infestation. Interviews with other staff confirmed that all shifts receive staff reports detailing resident assignments and needs, and that it is standard practice to check on all assigned residents at the beginning of each shift. Despite these procedures, the CNA failed to recognize her responsibility for the resident, resulting in a lack of supervision and care. This failure was determined to be neglect, as it did not meet the resident's physical, mental, and psychosocial needs as required by facility policy and regulatory standards.