Failure to Maintain Resident Dignity and Personal Hygiene
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by multiple observations and interviews involving three residents. One resident with anemia, hypertension, and anxiety disorder was observed with an uncovered, undated yellow gauze dressing on her forehead. The LPN applied the dressing without securing or covering it, despite the resident's preference for it to be covered to avoid feeling stared at. The Assistant Director of Nursing confirmed that the resident sometimes had the gauze covered for dignity reasons, but this was not consistently done. Another resident with traumatic brain injury, schizophrenia, and dysphagia, who was totally dependent on staff, was observed during incontinence care where a CNA leaned over him and roughly removed a soiled sheet while the resident's back was still on it. The resident was left with blood running down his neck from a bleeding sore, which was not cleaned, and staff failed to notify a nurse. Later, the resident, who was NPO, repeatedly requested water, but the nurse did not provide oral care as promised, and a cup of water with a straw was left at the bedside despite the NPO status. The resident's mouth was observed to be in poor condition, with a strong odor and peeling skin inside the mouth. A third resident with Parkinson's disease, dementia, and schizophrenia was observed multiple times with dried food on his mouth and shirt, long fingernails with a brown substance underneath, and a thick white film on his teeth. His hair was also observed to be disheveled. The resident was dependent on staff for personal hygiene, oral care, and grooming, but these needs were not met, as confirmed by both staff and family members. The facility's policy requires residents to be treated with kindness, respect, and dignity, but these standards were not upheld in the care provided to these residents.