Failure to Maintain Resident Dignity and Safe Care During Assistance and Transfers
Penalty
Summary
The facility failed to respect resident dignity and provide care in accordance with residents' rights for two residents with severe cognitive impairment. One resident with Parkinson's disease, muscle wasting, and repeated falls was dependent on staff for ambulation and required assistance with a walker and wheelchair. On the evening of her fall, staff interviews revealed that a registered nurse witnessed the resident fall, did not assess her or take vital signs, and responded with inappropriate and disrespectful language, including cursing at the resident and expressing frustration. The nurse physically lifted the resident from the floor by her arms and dragged her, without proper assessment or documentation of the incident. Other staff members reported feeling uncomfortable and concerned about the nurse's behavior, noting that the falls were not documented in the shift report and that the resident was visibly shaken and crying after the incidents. Another resident with muscle weakness and dementia, who required total assistance and mechanical lift transfers, was found to have significant bruising on both forearms. Staff interviews and documentation indicated that a CNA transferred the resident without the required mechanical lift, instead performing a manual pivot transfer and body lift. During the transfer, the resident was heard screaming in pain and fear, and was later observed to be visibly shaken and fearful. The CNA involved had only two days of training before working independently and admitted to transferring the resident without assistance or proper equipment. Other staff members witnessed the incident, reported their concerns to the nurse and DON, and noted that the resident's care plan was not followed during the transfer. The facility's policy requires that residents be free from abuse, neglect, and mistreatment, and that staff maintain a culture of compassion and caring, especially for those with cognitive or behavioral issues. Despite this, the actions and inactions of staff in both cases resulted in a failure to uphold resident dignity and provide care in a respectful and safe manner, as evidenced by inappropriate handling, lack of assessment, failure to follow care plans, and disrespectful communication.