Failure to Maintain Resident Dignity During Behavioral Incident and Personal Care
Penalty
Summary
The facility failed to maintain resident dignity and respect in two separate incidents involving two residents. In the first incident, a maintenance staff member intervened during an episode where a resident with schizophrenia and bipolar disorder was banging on the nurse's station door. Despite the resident's care plan indicating the need for staff to explain procedures and allow time for adjustment, the maintenance staff repeatedly told the resident to stop, then physically pulled the resident's wheelchair backward. This action resulted in the resident striking the staff member. Interviews with facility staff, including the maintenance supervisor and DON, confirmed that maintenance staff are not expected to intervene in behavioral situations and that the approach taken was inappropriate. In the second incident, a resident with depression, anxiety, and moderate cognitive impairment was observed with a urinal containing yellow liquid placed on his bedside table next to food and drink items. The resident expressed discomfort with the urinal's placement but felt unable to change the situation. The activities director acknowledged the urinal should not have been on the table and removed it, later providing a holder for proper storage. The DON confirmed that urinals should not be stored on surfaces used for eating and should be emptied and stored in designated holders after use. Both incidents were found to be inconsistent with facility policies and training, which emphasize respectful, empathetic responses to resident behaviors and proper handling of personal care items to maintain dignity. The failures in these cases had the potential to affect the emotional well-being of the residents involved.