Failure to Provide Necessary Care and Timely Assessment Resulting in Resident Neglect and Death
Penalty
Summary
A facility failed to protect a resident's right to be free from neglect by not providing necessary care and services to a totally dependent resident, resulting in the resident being found unresponsive and exhibiting physical signs consistent with having been deceased for several hours prior to discovery. The resident, an elderly female with severe cognitive impairment, was totally dependent on staff for all activities of daily living, including mobility, nutrition via gastrostomy tube, and required frequent monitoring and repositioning. Despite physician orders for regular care and assessments, documentation and interviews revealed that staff did not provide the required care or timely assessments during the shift preceding the resident's death. On the evening and overnight shifts, multiple staff members failed to adequately monitor or assess the resident. The assigned LPN reported seeing the resident sleeping at various times but did not check for responsiveness or breathing, and documentation was inconsistent with the resident's actual condition and care needs. The CNA assigned to the resident did not provide required care, such as repositioning, and incorrectly documented that the resident was unavailable for care, later admitting to confusing her with another resident. Another CNA arriving for the overnight shift found the resident cold and stiff to the touch but did not report these findings to a nurse. Interviews revealed that staff felt pressured by facility leadership to provide false witness statements regarding the incident. When the resident was eventually found unresponsive, staff initiated CPR and called emergency services, but EMS and hospital records indicated the resident had been deceased for several hours, as evidenced by rigor mortis and a significantly lowered core body temperature. The facility's failure to provide care, timely assess, and recognize a change in the resident's condition, as well as the failure to initiate life-saving interventions in a timely manner, resulted in Immediate Jeopardy. The facility's own policies defined neglect as failure to provide necessary goods and services to avoid harm, and staff interviews and documentation confirmed that required care was not provided.