Failure to Provide and Document Required Overnight Care Resulting in Resident Neglect
Penalty
Summary
The deficiency involves a failure to ensure that a resident remained free from neglect when required care was not provided during an overnight shift. A facility-reported incident submitted to the Office of Health Care Quality documented an allegation by Resident #75 that no staff provided care during the 11 p.m. to 7 a.m. shift on a specific date. A follow-up investigation form in the facility’s incident folder confirmed that the assigned Geriatric Nursing Assistant (GNA) did not enter the resident’s room to provide care during that shift. Review of the GNA task documentation for that night showed no entries for multiple care tasks, including bathing, bed mobility, oral hygiene, toileting, application of barrier cream after incontinence care, bowel elimination, urinary incontinence care, or use of foam ankle boots in bed as tolerated. During an interview, the Director of Nursing stated that care provided during a shift must be documented by the GNA, that there should not be blank spaces on the GNA task documentation, and that refusals and all care-related activities should be recorded. She acknowledged that if a task was not documented, there was no support to show it was completed, and confirmed that if care had been provided to the resident on that night shift, it should have been documented and not left blank.
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