Failure to Honor Resident Dignity and Respect in Care Delivery
Penalty
Summary
Surveyors identified multiple failures by facility staff to treat residents with dignity and respect during the provision of care and services. One resident with diagnoses including heart failure, seizure disorder, and anxiety, and who was cognitively intact, reported being told by CNAs to use her brief for toileting instead of being assisted to the bathroom, particularly at night. She described feeling 'nasty' and experiencing constipation as a result, and recounted an incident where she was left with feces partially expelled overnight. Observations confirmed the resident was left in the same clothing for several days, her hair was oily, and there was an odor present. Staff interviews corroborated that some CNAs refused to assist her to the bathroom and that concerns had been raised but not escalated to facility leadership. Additionally, staff were observed entering resident rooms without knocking or announcing themselves, including during times when residents were sleeping. Another resident, also cognitively intact and with significant physical care needs, reported only receiving one bath per week, delays in morning care, late medications, and missed pain cream applications. She described a specific incident where her call light was turned off without assistance, resulting in a 2.5-hour wait to be changed. She also reported inconsistent oral care and difficulty getting her clothes changed without help from her significant other. Staff interviews confirmed that missed showers and oral care were common, particularly on the second shift, and that staffing shortages contributed to these issues. A third resident, dependent on staff for most activities of daily living, reported feeling embarrassed and under duress after hearing staff discuss him and a former employee. Multiple staff members admitted to discussing the resident and rumors about a possible relationship and medication issues among themselves. The DON acknowledged receiving complaints from residents about dignity-related issues such as bathing, timeliness, and staffing, and stated expectations for staff to knock before entering rooms and to provide oral care twice daily. The facility's policy affirmed residents' rights to dignity, respect, privacy, and personal choice in care.