Failure to Prevent Abuse and Neglect Resulting in Resident Injury and Skin Breakdown
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in significant harm to two residents. One resident with severe cognitive impairment and multiple comorbidities, including cirrhosis, dementia, and functional quadriplegia, sustained a fractured left humerus while under the care of a certified nursing assistant (CNA). Multiple interviews and witness statements indicated that the CNA was observed being rough with the resident, with reports of yelling, pulling, and a loud bang heard during care. The resident was later found to have a painful, swollen arm, and was diagnosed with a displaced supracondylar fracture. There was no documentation or credible evidence of a fall, and several staff and family members reported concerns about the CNA's rough handling and verbal aggression toward residents. The facility's investigation relied on uncorroborated statements and failed to document or substantiate a fall as the cause of injury. Another resident, who was cognitively intact and dependent on staff for toileting and hygiene, developed multiple open areas of moisture-associated skin damage (MASD) and skin breakdown due to inadequate incontinence care. The resident and their family reported frequent delays in being changed, lack of regular showers, and persistent pain and burning in the affected areas. Direct observation confirmed the presence of feces and multiple open wounds on the resident's buttocks and thighs, with no evidence of recent peri-care or appropriate wound treatment. Review of care documentation revealed multiple shifts with no record of incontinence care or showers provided, despite care plan instructions for regular toileting, cleansing, and skin monitoring. Staff interviews confirmed that documentation of care was incomplete and that the standard of checking and changing incontinent residents every two hours was not consistently met. The wound care nurse and restorative nurse acknowledged the presence of skin breakdown and the need for regular application of barrier creams, but also confirmed that care was not always provided as required. The facility's failure to ensure consistent, appropriate care and to protect residents from abuse and neglect directly resulted in physical harm and pain for the affected residents.