Failure to Implement Abuse and Neglect Policies Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically for a resident with severe cognitive impairment and multiple medical conditions, including dementia, stroke, diabetes, epilepsy, and hypertension. The resident was care planned as dependent on two staff for transfers and required a mechanical lift with two-person assistance. Despite these documented needs, the resident was left in a shower chair with only one CNA present, who turned away to retrieve the mechanical lift, leaving the resident unattended. During this time, the resident fell from the shower chair and sustained acute fractures to the right great toe and first metatarsal, as confirmed by x-ray. Progress notes documented the resident's pain and subsequent administration of pain medication, as well as a referral to orthopedics. Interviews with staff revealed that the CNA was aware the resident required two-person assistance but proceeded alone due to staffing shortages. The CNA also reported having to perform two-person assists alone on several occasions. Further interviews indicated a lack of clarity among staff regarding abuse and neglect reporting procedures, and there was no documentation of in-service training following the incident. The facility's policies defined neglect as the failure to provide necessary goods or services to avoid harm, and provided an example similar to the incident that occurred. The facility did not report the fall as neglect, nor did it provide immediate in-service training to address the deficiency.