Failure to Provide Timely Care and Services Resulting in Resident Neglect
Penalty
Summary
Facility staff failed to protect two residents from neglect by not providing timely care and necessary services. One resident with severe cardiac disease and nephrostomy tubes experienced a significant weight gain, worsening edema, and shortness of breath over a 43-day stay. Despite clear care plan instructions and hospital discharge orders to notify cardiology for specific weight gains, there was no evidence that the cardiology physician was ever contacted. The resident's fluid intake was consistently below the ordered restriction, and documentation showed inadequate provision of fluids and bathing, with only three bed baths recorded and no showers provided. The resident's family was not notified of her worsening condition, and she was not sent to the emergency room until three hours after the order was received, ultimately expiring in the hospital two days later. Another resident with multiple comorbidities, including diabetes, chronic kidney disease, and heart failure, reported severe abdominal pain and vomiting. The resident's complaints began late at night and persisted for over 11 hours before a nurse practitioner was notified. During this period, the resident continued to experience pain, was unable to eat, and required repeated pain assessments and interventions. The facility staff did not notify the resident's responsible party of the change in condition until more than 17 hours after the initial complaint. The resident was eventually transferred to the hospital, where she was diagnosed with septic shock and a perforated ulcer. Staff interviews and clinical record reviews confirmed delays in notification, assessment, and treatment for both residents. The facility failed to provide required goods and services, including timely medical intervention, adequate hydration, hygiene, and communication with family members. These failures resulted in neglect as defined by federal regulations, with harm identified for one resident and significant delays in care for the other.