Failure to Provide Required ADL Assistance and Supervision Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dependence for activities of daily living (ADLs), and multiple medical conditions including pneumonia, coronary artery disease, heart failure, and a stage two pressure ulcer, did not receive required care and assistance as outlined in their care plan. The care plan specified frequent turning and repositioning, assistance with toileting and dressing, and regular safety checks, particularly due to the resident's incontinence, oxygen therapy, and pressure ulcer. On the evening in question, video surveillance and documentation review revealed that the assigned Certified Nurse Aide (CNA) did not provide the necessary care, including transferring the resident to bed, changing clothing, or performing safety checks, despite documentation indicating otherwise. The resident was last seen in their wheelchair, fully clothed, and not in bed as was their usual routine. Staff interviews and video evidence confirmed that no staff entered the resident's room for an extended period during the evening shift. The resident was later found on the floor, face down between the bed and wheelchair, with their oxygen cannula dislodged and sustaining lacerations to the forehead and neck. The resident was non-verbal, short of breath, and subsequently pronounced deceased at the facility. The incident investigation determined that the resident experienced a medical event leading to a fall, and due to their condition, was unable to get up or call for help, resulting in further injury. Interviews with staff revealed lapses in communication and assignment handoff, with the CNA stating they did not receive a report or assignment sheet and did not provide care to the resident. The LPN on duty acknowledged noticing the resident was not changed or in bed but did not follow up to ensure care was provided after instructing the CNA. Other staff and the resident's family confirmed that the resident was typically in bed early in the evening and always required assistance. The failure to provide care and supervision as required by the care plan resulted in actual harm to the resident.