Resident Suffers Four Hours Without Care

Patewood Rehabilitation & Healthcare Center has been cited after a resident waited more than four hours to have their adult diaper changed. The resident requested help multiple times, and no nursing home staff assisted in this time.

A Certified Nursing Assistant (CNA) responded to the resident’s call light in their room at 8:00 am. The CNA told the resident that the staff was in the middle of passing out breakfast trays, and that she would come back soon to help. The CNA returned at 10:45 am and provided perineal care, but did not complete the morning care that the resident had requested more than two hours prior. The CNA told the resident, yet again, that they would return in two hours. When the CNA failed to show in the next two hours, the resident called again for help. The resident’s son and family visited in the middle of the day and noted a distinct smell in the room, as if the resident had not been changed regularly. The resident eventually got help at 3:00 pm, four hours and fifteen minutes later.

The CNA stated that they came to help the resident a few minutes after 3:00 pm because they saw that the resident’s call light was on. The CNA said that the resident was yelling and cursing when they arrived, shouting that four CNAs had ignored the call light. The CNA told the resident that they had no control over other aides and that they did not know the resident had waited for over an hour, but that they would help change the resident. According to the CNA, the resident continued to yell, so they asked for help from another CNA and a Licensed Practical Nurse (LPN).

The nursing home’s internal investigation states that when the CNA came to help the resident at 3:00 pm, a verbal altercation ensued. An LPN asked the CNA to leave the resident’s room. The LPN’s statement showed that the resident was crying, saying that their light had been on for a long time with no response. The resident claimed that they had not received care for hours and could smell themselves. Instead of responding to the resident’s concerns, the CNA insulted the resident and pointed their finger, arguing loudly with the resident. The LPN had to ask the CNA to leave the resident’s room numerous times before they walked out, slamming the door as they left.

The resident shared with the nursing home’s social services that they were shaken up by the incident, fearing that the CNA would try to come to the nursing facility and harm them. The psychological effects of nursing home abuse can last long past a specific event. This resident trusted the nursing home and nursing staff to care for them in their most vulnerable moments, and that trust was betrayed when one CNA failed to provide daily care. Other nursing staff also ignored the resident, even when their call light was active for more than an hour.

The CNA stated in an interview with the state investigator who compiled this citation report that this specific resident needed their vital signs taken every two hours because they had a fever. They also claimed that they changed the resident every time vital signs were taken, which was not the situation the resident or other nursing staff had described when reporting this incident. In the statement of one nursing staff member, the resident shared that their call light had been taken by the CNA.

The facility’s investigation did find the resident’s claims of neglect to be substantiated. In this case the resident’s reported neglect was witnessed by other staff members as well as their families. When a nursing home provides poor care to one or more residents, it is important that residents and their families speak up. Knowing the signs of abuse and neglect is the first step to protecting loved ones in a nursing home. This resident’s family was able to recognize a sign of neglect – a foul smell in a resident’s room – and the resident reported the issue to the facility.

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