Failure to Protect Resident from Neglect and Verbal Mistreatment
Penalty
Summary
A resident with multiple complex medical conditions, including Type II Diabetes Mellitus with hyperglycemia, hemiplegia, bilateral above-knee amputations, chronic obstructive pulmonary disease, dysphagia, and a history of gastrointestinal hemorrhage, requested a snack during the night because he was not feeling well. The resident, who was alert and oriented with a BIMS score of 15, reported that a nursing aide responded to his request by telling him there were no sandwiches and to "shut up and go to sleep." The following morning, the resident was found to have a critically low blood glucose level of 40 mg/dl, requiring immediate intervention per hypoglycemia protocol. Documentation and staff statements revealed that the resident's request for food was not accommodated, and there was conflicting information regarding the staff's response. The nursing aide and an LPN both stated that there were no sandwiches available, but the aide denied using inappropriate language. The resident maintained that he was dismissed and spoken to disrespectfully. Medical records indicated that the facility was aware of the resident's hypoglycemic episode and had implemented new dietary and insulin orders the same day, suggesting awareness of the incident's circumstances. Despite the resident's report of verbal mistreatment and the documented hypoglycemic event, the facility's investigation concluded that there was insufficient evidence to substantiate verbal abuse and stated that no physical or emotional harm was identified. However, the report shows that the resident's request for a snack was not met, and the facility failed to ensure the resident was free from neglect, as required by regulation.