Resident Neglect Resulting in Skin Injury from Prolonged Bedpan Use
Penalty
Summary
A resident with a history of Parkinson's Disease, morbid obesity, and Type 2 Diabetes Mellitus was admitted and later readmitted to the facility. The resident was cognitively intact per recent assessment and required assistance with toileting and transfers. On the day of the incident, the resident experienced a significant change in condition, including lethargy and hypoglycemia, which led to her being sent to the hospital. During preparation for transfer, staff discovered the resident had been left on a bedpan for an extended period, resulting in multiple skin injuries, including abrasions and sheared areas on the buttocks and upper legs. Facility documentation and interviews revealed that no CNA claimed responsibility for placing the resident on the bedpan, and the assigned CNA left the facility without providing a statement or participating in follow-up. The resident reported being left on the bedpan for over three hours, unable to locate her call light, and eventually fell asleep. Observations and hospital records confirmed the presence of significant skin injuries consistent with prolonged pressure and shearing from the bedpan. Staff interviews indicated that standard practice required CNAs to check on residents within 5-30 minutes of bedpan use, and that the resident was typically able to request assistance but was unable to do so due to her change in condition. The facility's own investigation and staff statements acknowledged that the resident did not receive the necessary care and supervision to prevent neglect, particularly in light of her acute change in condition. The lack of timely removal from the bedpan and failure to monitor the resident's needs directly resulted in physical harm, as evidenced by the documented wounds. The incident was recognized by staff and administration as a failure to provide required goods and services, constituting neglect.