Failure to Protect Resident from Abuse and Neglect by Staff
Penalty
Summary
A resident with multiple complex medical conditions, including Alzheimer's disease, dementia, protein-calorie malnutrition, and significant physical impairments, was not provided with timely and appropriate care by facility staff. The resident was completely dependent on staff for all activities of daily living, including repositioning, incontinence care, feeding, and medication administration. According to the care plan, staff were instructed to anticipate and meet the resident's needs, including frequent position changes and incontinence care at least every two hours. However, interviews and review of camera footage revealed that staff often failed to enter the resident's room for extended periods, sometimes up to six or eight hours, leaving the resident without necessary care. On a specific occasion, two CNAs transferred the resident using a mechanical lift and toilet sling. During the transfer, the resident was improperly positioned, resulting in significant pain and distress, as evidenced by the resident's crying, screaming, and yelling. The resident continued to have a bowel movement during the transfer, and instead of repositioning the resident or returning her to the toilet as requested by her power of attorney, the staff placed a garbage can under her, forcing her to have a bowel movement in it. The staff then left the resident on her bed without completing incontinence care or ensuring she was safely positioned, leaving her soiled and in pain. The resident's family and private caregivers reported that they were frequently required to provide all aspects of care, including repositioning, feeding, and medication administration, due to staff neglect. Facility leadership was made aware of these concerns, but failed to take appropriate action. The interim DON acknowledged receiving multiple complaints from the resident's power of attorney and confirmed that staff should be providing care every two hours. Despite requests to prevent the involved CNAs from caring for the resident, they continued to do so. The administrator in training admitted that the facility did not follow its abuse policy and did not properly report or investigate the incident. The facility's own policy states that residents must be free from abuse and neglect, and that staff must intervene to prevent such occurrences, but these standards were not upheld in this case.