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F0600
D

Neglect Due to Refusal of Care by Nurse Aides

Pembroke, North Carolina Survey Completed on 11-21-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when two nurse aides (NAs) on the 3:00 PM to 11:00 PM shift refused to provide necessary care to a dependent resident with hemiplegia, cerebral infarction, and anxiety disorder. The resident, who was cognitively intact and fully dependent on staff for transfers and incontinence care, requested assistance to be transferred to bed and to receive incontinence care after her evening routine. The NAs entered the resident's room with a mechanical lift, turned off her air conditioner against her wishes, and left the room without providing care after the resident used a curse word in response. The resident was left sitting in her electric wheelchair in a semi-private room, exposed to her roommate, and was not assisted to bed or provided incontinence care for several hours. The resident's roommate confirmed the sequence of events, stating that the NAs refused to provide care after the resident expressed her displeasure at the air conditioner being turned off. The roommate observed that the resident remained in her wheelchair until after midnight, when the next shift arrived. When the night shift NAs finally provided care, they found the resident's brief heavily soiled with dried, caked bowel movement, indicating that incontinence care had been delayed for a significant period. The resident expressed feelings of embarrassment and humiliation due to being left in this condition in front of her roommate. Interviews with the involved NAs revealed that they refused to provide care because they felt disrespected by the resident's language. Both NAs acknowledged that they left the facility at the end of their shift without assisting the resident. The nurse on duty was informed of the incident but was not aware that care had not been provided before the NAs left. The night shift NAs and nurse confirmed the resident's distress and the delay in care. The deficiency was identified through observations, record review, and interviews, demonstrating a failure to protect the resident from neglect and to uphold her right to receive necessary care.

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