Failure to Prevent Neglect and Abuse, Resulting in Wound Deterioration and Resident Distress
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, as evidenced by the lack of implementation of required interventions and inadequate wound care management. One resident, a cognitively intact female with paraplegia and multiple complex medical conditions including stage 3 and 4 pressure ulcers, osteomyelitis, and a suprapubic catheter, did not receive prescribed wound care treatments, turning and repositioning, or assistance with transfers to a chair as ordered. Documentation and interviews revealed that wound dressings were not changed as required, the resident was not turned or repositioned according to care plans, and she was left in soiled conditions for extended periods. The resident and her family repeatedly reported these issues to facility leadership, but corrective actions were not taken, resulting in wound deterioration, severe sepsis, and hospitalization for surgical wound debridement. Staff interviews indicated confusion and lack of accountability regarding wound care responsibilities, with several nurses and CNAs stating that wound care was often missed or improperly delegated, especially when the designated wound care nurse was unavailable. Observations confirmed that wound dressings were not changed daily as ordered, and some residents were found with dressings that had not been replaced for multiple days. The facility's own wound care consultant noted that dressings were frequently saturated and that the resident was not being mobilized as required, further contributing to the risk of infection and poor wound healing. Additionally, the facility failed to protect another resident from alleged verbal and physical abuse by a staff member, allowing the accused staff to continue providing care to the resident after the allegation was made. The resident expressed fear of the staff member, yet no immediate action was taken to prevent further contact. These failures were identified as Immediate Jeopardy situations by surveyors, as they placed residents at risk for physical harm, mental anguish, and neglect. The facility's policies required prompt identification and intervention in cases of abuse and neglect, but these were not followed, resulting in significant deficiencies in resident care.