F0600

J

Failure to Reassign Staff Leads to Widespread Resident Neglect on One Hall

Pittsburgh, Pennsylvania Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect 12 residents from neglect when an entire hall (rooms 209-A through 217-B) was left without a nursing assistant (NA) for the day shift, and no reassignment of staff was made to cover those residents. During a tour of the second floor, an NA reported that only two NAs were on the floor because the third did not show up, and that residents down one hall had not been “touched” since the overnight shift. Review of the daily assignment sheets confirmed that the West assignment (rooms 209-A through 217-B) was assigned to an NA who failed to report to work and that this assignment was not reassigned to another staff member. A licensed practical nurse (LPN) stated that when she learned there was no third NA, she informed the supervisor and was told nurses would need to help the NAs, but she said she could not help due to difficulty walking and confirmed that no care had been provided since the overnight shift.

Subsequent observations and resident interviews showed that all 12 residents in rooms 209-A through 217-B, who required assistance with activities of daily living, remained in bed in disheveled condition and had not received morning care, incontinence care, repositioning, or assistance getting out of bed. Multiple residents reported that no one had come in to clean them, change their briefs, or help them get up, despite some having conditions such as diabetes, hemiplegia, paraplegia, heart failure, Parkinson’s disease, osteomyelitis, peripheral vascular disease, COPD, depression, and difficulty walking. Several residents specifically stated that their briefs had not been changed since the previous night, that they had experienced diarrhea and remained soiled, and that they usually received skin cream but had not received it that day. One resident reported having to seek out staff to request to see the nurse practitioner because no one had checked on them.

Staff interviews corroborated that residents in the affected section did not receive care. An RN stated she offered to help but that the LPN refused, saying she did not want to help with care and was functioning as a cart nurse. The LPN acknowledged that no care, including incontinence care and repositioning, had been provided to the residents in that section and that the whole section had been without an NA all day. NAs confirmed that no morning care, baths, showers, dressing, getting residents out of bed, teeth brushing, or incontinence care had been done for that section. A supervising RN reported being aware that one NA did not show up, notifying the DON and scheduler, and informing nurses that they would have to assist, but stated that the two NAs did not help by splitting the floor into two sections instead of three, resulting in residents not receiving care. The administrator and DON confirmed that the facility failed to ensure residents were free from neglect and failed to timely and effectively manage 12 allegations of neglect, creating an Immediate Jeopardy situation for all 12 residents.

The facility’s own abuse, neglect, and mistreatment policy stated that the facility prohibits neglect and is responsible for providing a safe environment, preventing and reporting suspected or alleged neglect, and ensuring that incidents are investigated by the administrator and DON. Neglect was defined in the policy as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Despite this policy, the facility did not ensure that all residents were assigned to working staff when the scheduled NA failed to report, and did not ensure that nurses and NAs provided necessary care to the residents in the unstaffed section. The State Agency notified the nursing home administrator and DON twice on the same day about the 12 allegations of neglect and the ongoing lack of care in the affected section before Immediate Jeopardy was called due to resident neglect of the 12 residents.

Removal Plan

• All residents will be assessed and a full body head to toe skin check will be performed for any indications of skin concerns; any identified concerns will be immediately addressed; findings will be documented in resident medical records and attending physician and responsible parties will be notified of adverse findings.
• Facility Medical Director, attending physician for resident (if different from Medical Director), and responsible party for resident will be notified of the neglect that was identified, as well as any potential indications of skin concerns or ill effects secondary to alleged neglect.
• Report will be called into Adult Protective Services.
• Department of Health event report will be completed and applicable PB22's.
• Resident care plans will be updated as applicable to reflect changes as identified.
• Facility NHA, DON, Scheduler and/or Designee will review the current schedule and ensure adequate staff are scheduled to ensure that care is provided to avoid neglect.
• All current nursing staff, including agency, will be educated on facility policy for abuse and neglect and sign the education prior to their next working shift.
• DON/Designee will conduct audits for resident care needs to ensure that no abuse or neglect is identified.
• Results of the audit will be reported to Ad Hoc Quality Assurance Performance Improvement (QAPI) committee.