Delayed and Inadequate Night Shift Care Due to Improper Rounding and Lighting
Penalty
Summary
Staff failed to provide timely and appropriate care to a resident who required substantial assistance with daily activities, including eating, personal hygiene, and transfers. On the overnight shift, rounds were not completed and care was not provided to the resident until approximately four hours after the shift began. When care was eventually given at around 3 a.m., it was performed with the lights off or dimmed, preventing staff from adequately assessing the resident's condition. Multiple staff members, including a CNA and an RN, reported not seeing the resident's face during their rounds due to the darkened room. The resident, who had diagnoses of generalized muscle weakness and depression and lacked decision-making capacity, was later found to have multiple facial bruises and discolorations. Facility policy required staff to make rounds at the beginning of each shift to ensure residents' safety and to provide care under appropriate conditions, including turning on lights to properly assess residents. The failure to follow these procedures resulted in delayed care and an inability to recognize changes in the resident's condition.