Resident Left Unassigned and Unattended on Floor in Feces Overnight
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not ensuring that staff checked on the resident every two hours for toileting and care needs during an overnight shift. The resident had diagnoses including metabolic encephalopathy, incontinence, impaired mobility, osteoarthritis, and communication deficits related to a previous stroke. An MDS dated 12/31/2025 documented that the resident had intact cognition for daily decision-making, required partial assistance for toileting, dressing, toilet transfers, and walking, and used a wheelchair for mobility. The resident also required supervision for multiple ADLs, including bathing, hygiene, transfers, and positioning. On the 11 PM to 7 AM shift, the CNA assignment sheet for that night did not list any CNA assigned to this resident. CNA1 stated that he was not assigned to the resident and that the assignment sheet did not reflect any staff responsible for the resident’s care. As a result, the resident was not checked or assisted with toileting or incontinent care for an extended period. According to interviews, at approximately 5 AM, LVN2 found the resident in her room sitting on the floor in feces and informed the RN Supervisor. CNA1 later went to assist the resident around 6:20 AM after being instructed by the RN Supervisor and found the resident still on the floor, sitting in stool with feces on her body. CNA1 and CNA3 cleaned the resident while she remained on the floor but were unable to lift her back into bed due to her weight and inability to assist with the transfer. CNA1 reported that the RN Supervisor declined to help, stating it was almost the end of his shift, and provided no assistance. CNA1 further stated that he informed the RN Supervisor that he and CNA3 were ending their shift while the resident remained on the floor. LVN2 confirmed that the resident stayed on the floor from the time she was found at approximately 5 AM until the morning shift arrived at 7 AM to assist with lifting and transferring the resident back to bed. The DON and DSD reported that they were not notified at the time of the incident, and the DON stated that no licensed nurse had informed her that the resident was found on the floor, so no root cause analysis or investigation had been conducted. Facility policies on abuse prevention and reporting defined neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required prompt and thorough investigation of neglect or injuries of unknown source.
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