Failure to Fully Investigate Incident Involving Prolonged Time on Bedpan
Penalty
Summary
The facility failed to fully investigate a potential incident of abuse or neglect involving one resident, as required by its Abuse Investigation and Reporting policy. The policy, reviewed on 10/8/25, required that all reports of abuse, neglect, exploitation, mistreatment, or injuries of unknown origin be promptly reported and thoroughly investigated, including interviewing the person reporting the incident and other residents who received care from the accused employee. The resident involved, who had diagnoses including high blood pressure, depression, and chronic pain, was re-admitted to the facility on an unspecified date. Facility records showed that on 1/1/26, the resident was placed on a bedpan by an LPN, who then asked an NA to watch for the call light and remove the bedpan. The NA’s shift ended at 4:00 a.m., and during subsequent rounds the LPN and an RN found the resident still on the bedpan, approximately two hours later; no injuries were noted on assessment. During interviews, the DON acknowledged there was no written proof that residents were interviewed about the care and services they received on the night shift when the incident occurred. The NA stated she was asked to stay past her shift, which ended at 3:00 a.m., and that she remained until 3:30 a.m., but reported she was unaware the resident had been placed on a bedpan. The LPN reported that a major snowstorm had caused multiple call-offs, leaving only an RN, the LPN, and one NA to cover the overnight shift, and that she and the RN assisted the NA with resident care, including placing the resident on the bedpan. The LPN also stated she could not locate the NA at 4:00 a.m. when rounds began and described prior derogatory remarks from the NA that led to hard feelings between them. An attempt to interview the RN by telephone was unsuccessful. The Nursing Home Administrator confirmed that the incident involving the resident was not fully investigated and that resident statements regarding their care by staff during the night shift were not obtained, in violation of 28 Pa. Code 201.149(a) and 201.18(e)(1).
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