Failure to Monitor and Provide Nighttime Care Resulting in Resident Neglect
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not providing adequate monitoring and care during the night shift. A resident with multiple medical conditions, including COPD, congestive heart failure, diabetes, and atherosclerotic heart disease, required supervision or assistance with activities of daily living (ADLs) and was at risk for falls. Care plans indicated the need for staff to check for incontinence, provide assistance with transfers, and ensure the call light was within reach, but there was no documentation that the resident was independent with ADLs or refused care. On the night in question, staff did not enter the resident's room or visualize her for the entire 8-hour night shift, relying instead on the assumption that the resident would come out or use the call light if assistance was needed. Staff statements and interviews revealed that the nurse and CNA assigned to the resident's unit did not physically check on the resident during the night, with the CNA last seeing her between 9:00 p.m. and 10:00 p.m. and the nurse not seeing her at all. The QMA assigned to the unit opened the resident's door but did not fully enter or confirm the resident's presence, only assuming she was in bed. Documentation in the resident's records, including progress notes and care logs, lacked entries indicating care or monitoring was provided after late evening, and there was no evidence the resident refused care or requested privacy that would have precluded staff checks. Staffing levels were reported as typical for the facility but were described by multiple staff as insufficient to allow for regular two-hour checks, especially during night shifts. The resident was found deceased on the floor between her bed and wheelchair by the oncoming shift nurse the next morning, with rigor mortis present, indicating she had been dead for several hours. The coroner and police were notified, and the preliminary autopsy indicated death from natural cardiac causes with no suspicious trauma. Staff interviews confirmed that routine two-hour checks were expected but not performed, and the resident's care plan did not document any preference to avoid such checks. The facility's policies required regular monitoring for safety and care needs, but these were not followed, resulting in the resident not being observed or assisted throughout the night.