Violation of Resident Dignity and Rights
Penalty
Summary
The facility failed to honor a resident's right to dignity and self-determination, as evidenced by an incident involving a certified nurse aide (CNA) and a resident with diagnoses including anxiety, a fractured right humerus, and diabetes. The resident, who was cognitively intact, experienced an inappropriate interaction with CNA #4. The CNA provided care despite the resident's refusal, leading to feelings of shame and humiliation. The incident occurred when CNA #4 touched the resident in the genital area without announcing their presence and continued to do so even after the resident asked them to stop. Later, the CNA insisted on providing personal hygiene care despite the resident's preference to perform their own care, further violating the resident's dignity. Interviews with other staff members, including a registered nurse, a licensed practical nurse, and a social worker, confirmed that CNA #4's actions were inappropriate and violated the resident's rights. The resident was visibly upset and embarrassed by the incident, which was reported to have occurred in the early hours of the morning. The facility's policy on resident choice and rights emphasizes the importance of respecting residents' decisions and maintaining their dignity, which was not upheld in this case. The Director of Nursing acknowledged the dignity concern, and the CNA involved denied the allegations, stating they would not force care on a resident who refused it.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The resident noted to be adversely affected by an employee’s action which denied them their right to be treated with respect and dignity was assured that employee would no longer provide them care. The resident was seen by the social worker post incident but declined to discuss the incident further. The resident has since discharged. The employee cited in the deficient practice was immediately removed from duty upon notification of the event, did not return to work post incident and is no longer employed at the facility. All residents have the potential to be affected. All resident progress notes and incident reports for the past 60 days will be reviewed by the Director of Nursing/designee to identify any incidents of actual or potential abuse, neglect or mistreatment. Any identified incident will be reviewed to ensure each has been thoroughly investigated, reported timely to the Department of Health, staff alleged to have committed abuse immediately removed from contact with residents, care plans updated, and measures have been initiated to prevent recurrence. The facility policy for Resident Rights has been reviewed and remains appropriate. Resident Rights in-servicing is mandatory yearly for all facility staff and is part of the orientation program for new hires. Printed versions of the New York State Resident Rights Handbook are readily available on all units and in common areas. The facility completes satisfaction surveys quarterly with responsible parties and monthly with a random selection of long-term residents and new admissions. All facility staff will receive additional in-service training, specific to the residents' right to refuse care, and to always be treated with dignity and respect. These corrective actions will be monitored via random unannounced resident-care audits to assure all physical care interactions and verbal communications are conducted in a manner that affords the resident dignified, respectful care. Ten compliance audits will be completed by nurse managers/their designees, weekly for six weeks. These audits will include completion with families or responsible parties of those cognitively impaired to ensure treatment of [REDACTED]. These audit results will be placed on the agenda of both the monthly (for the next three months) and the quarterly Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Nursing will be responsible for ongoing compliance with these corrective measures.