Failure to Maintain Resident Dignity and Address Expressed Needs
Penalty
Summary
The facility failed to maintain resident dignity for two individuals with significant cognitive impairment. One resident, who was severely cognitively impaired and required a wheelchair for mobility, was observed sitting in a congested common area near the nursing station. Without being provided privacy, a therapist exposed both of the resident's legs to discuss his wounds in front of others, and an LPN administered oral medications in the same public setting, using the medication cup to open the resident's mouth. The LPN stated that she had not considered the appropriateness of administering medications in a common area and had not asked the resident about his preference for medication administration location. The resident's care plan did not include any specific interventions regarding medication administration in a common area. Another resident, also cognitively impaired and unable to complete a mental status interview, was observed repeatedly asking for help while seated in a high-backed wheelchair in front of the nursing station. The resident expressed discomfort and a desire to leave the area, but staff responded by turning on music and moving her in front of the radio before walking away. Later, the resident voiced that her pad was soiled, which, according to her care plan, indicated a bowel movement, but her needs were not addressed at that time. The care plan for this resident included interventions to support communication and ensure her needs were met when voiced, but these interventions were not followed during the observed incidents.