Failure to Provide ADL Care and Protect Residents From Intimidation and Abuse
Penalty
Summary
A staff member failed to provide required care and maintain respect and dignity for a dependent resident when a GNA assigned to Resident #10 did not provide any activities of daily living (ADL) care for an entire shift. The facility’s investigation documented that the GNA admitted he did not provide care all day, stating he believed the resident was a “no male” caregiver case, despite having signed off in documentation as providing ADL care to this resident on the previous day and earlier in the month. The resident’s MDS, completed shortly after the incident and reflecting the look‑back period that included the date of the allegation, showed the resident was dependent on staff for all ADLs, frequently incontinent of bladder, and always incontinent of bowel. The LPN assigned to the resident that day reported the resident never complained and that she did not notice the resident soiled, even though the MAR showed she had signed for applying powders and creams to multiple body areas that would have required assessment and recognition of any incontinence needing care. Another deficiency involved failure to protect a resident from intimidation and potential abuse by a respiratory therapist (RT). The RT documented that a ventilator‑dependent resident was repeatedly disconnecting from the ventilator and described the resident as combative, suggesting the resident be sent to the hospital if restraints were not used. A GNA present during the interaction reported that the RT was loudly and aggressively demanding help and stated that if the resident was not tied down, the resident would be sent out, and further reported that the RT told the resident that his patients know not to hit him because he hits back. The LPN caring for the resident acknowledged familiarity with the abuse policy and stated she knew the RT should have left but felt stuck due to working on a ventilator unit. She reported that she first texted her unit manager about the RT’s behavior later that afternoon and received only a brief response, and that she did not escalate the concern until the end of the shift, by which time the RT had gone home. The facility officially reported the incident to the state agency several hours after the onset of the RT’s documented aggressive behavior toward the resident.
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