Failure to Prevent Resident Neglect During Transfers and Incontinence Care
Penalty
Summary
The facility failed to protect residents from neglect, as evidenced by three separate incidents involving residents with significant medical needs. One resident, who had a history of cerebral infarction, hemiplegia, and major depressive disorder, required two-person transfers using a mechanical lift according to her care plan. Despite this, a staff member attempted to transfer her alone, resulting in the sling detaching and the resident falling, which caused a comminuted fracture and significant pain. Another resident, with non-dominant sided hemiplegia and dysphagia following a stroke, filed a grievance stating that incontinence care was not provided when a specific CNA was on duty. Review of camera footage confirmed that the CNA only attended to the resident once during an overnight shift, substantiating the resident's claim of neglect. The resident was subsequently assessed, and no evidence of physical or psychosocial harm was found following the incident. A third resident, diagnosed with severe vascular dementia, chronic kidney disease, and diabetes, was found soiled at the end of a shift, indicating that incontinence care had not been provided. Facility investigation and camera footage revealed that the same CNA had extended absences from the floor and provided minimal care to residents during the shift. The investigation confirmed that the CNA failed to perform required care for this resident, though no physical or psychosocial harm was identified upon assessment.