Failure to Ensure Respectful Communication and Dignity for Resident with Hearing Impairment
Penalty
Summary
A resident with spinal cord disease and post-traumatic stress disorder, who was cognitively intact and dependent on staff for emotional, intellectual, physical, and social needs, experienced a lack of respect and dignity from a Certified Nursing Assistant (CNA). The resident, who had difficulty hearing, reported that the CNA entered her room, ignored her question, and then began yelling and waving her arms above her head. The resident expressed feeling embarrassed, afraid, and unable to understand the CNA due to her hearing impairment. Another staff member had to intervene and remove the CNA from the room. Multiple interviews corroborated the resident's account, including statements from another resident, a family member, a licensed nurse, and the Director of Nursing (DON). The family member noted that staff failed to use the available whiteboard to communicate with the resident, despite her hearing difficulties. The licensed nurse confirmed that the CNA was defensive and yelled at the resident when asked to provide assistance. The DON acknowledged awareness of the incident and admitted that the facility did not follow up on the resident's psychosocial or emotional needs. The facility's policy on communication and respect and dignity was requested but not provided.
Plan Of Correction
F557: Respect and Dignity 1. Immediate Corrective Action for the Identified Deficient Practice: The resident(s) involved in the identified incident were immediately assessed to ensure their physical and emotional well-being. Staff members involved were counseled and re-educated on residents' rights related to respect and dignity. 2. Measures to Identify Other Residents Potentially Affected: No other residents were affected by this deficient practice. 3. Systemic Changes to Prevent Recurrence: • All staff will receive in-service training on Residents' Rights, with a focus on respect, dignity, communication, and sensitivity. Ongoing education will be added to the facility's annual training schedule and orientation for all new hires. • Social Services and Department Heads will incorporate random resident interviews into weekly rounds to monitor staff-resident interactions and ensure dignity is preserved. 4. Monitoring to Ensure Sustained Compliance: • The Administrator or designee will conduct monthly audits of resident interactions on all shifts for the next 6 months using a standardized Respect & Dignity Observation Tool. • Any issues identified will be brought to the Quality Assurance and Performance Improvement (QAPI) committee for review and action planning. • Results of the audits and interviews will be tracked, trended, and reviewed at quarterly QAPI meetings. 5. Completion Date: May 18, 2025 F 557