Resident Left Unattended and Deprived of Care Following Staff Argument
Penalty
Summary
A resident with diagnoses including congestive heart failure, diabetes mellitus, morbid obesity, anxiety, and depression, who was cognitively intact and dependent on two or more staff for transfers and personal care, was deprived of care and left in a vulnerable state. On the evening in question, the resident requested assistance with her usual nighttime routine, which involved transfer from a recliner to bed, cleaning, and changing into clean clothes. Two CNAs responded, but an argument ensued regarding the resident's care preferences. The resident asked one CNA not to return, after which both CNAs left her on the bed, soiled with urine, without a blanket, and with her call light and personal items out of reach. The resident's repeated calls for help went unanswered for approximately an hour, during which she became increasingly distressed, cold, and anxious. Multiple staff interviews confirmed that the resident was left unattended and that her requests for assistance were ignored. The resident was found later by another CNA, who provided care and comfort. The resident reported ongoing fear and anxiety, especially as the staff involved continued to work in the facility and pass by her room. The incident was not documented in the progress notes for that day, and the resident's anxiety and requests for medication increased following the event. Staff interviews revealed a lack of training, confusion about protocols, and failure to respond appropriately to the resident's distress and allegations of abuse. Leadership in the facility, including the DON and charge nurse, failed to address the resident's immediate concerns or investigate the incident in a timely manner. The DON was made aware of the situation but did not intervene or follow up with the resident, and staff were directed to ignore the resident's calls for help. The facility's abuse prevention policy required immediate reporting and investigation of abuse allegations, but these procedures were not followed. The resident's care plan, which included specific instructions for communication and reassurance, was not adhered to during the incident.