Resident Left in Soiled Brief and T-Shirt in Dining Room During Behavioral Episode
Penalty
Summary
A resident with diagnoses including severe unspecified dementia with behavioral disturbances, anxiety disorder, cognitive communication deficit, seizures, and difficulty walking experienced a behavioral episode while being assisted with a brief change. The resident became verbally agitated, exhibited signs of psychosis, and began yelling and making accusations against staff. During the episode, the resident grabbed and injured a CNA, attempted to strike staff with a call light, and threw items in the room. In response, staff, including an LPN and CNA, removed the resident from the room and transferred the resident to the dining room as a behavioral intervention. The resident was left in the dining room wearing only a soiled brief and a t-shirt, with the curtains drawn back, exposing the resident to view. Staff left the resident alone in the dining room, closed the door, and observed the resident through the windows. While in the dining room, the resident continued to display aggressive behaviors, including attempting to remove the television from the wall, swinging the television cord at staff, and throwing the remote control. The LPN attempted to calm the resident by offering food, drink, and medication, with the resident eventually accepting medication and calming down. Throughout the incident, the resident remained in a soiled brief and t-shirt in a common area, with the curtains open, which was confirmed by the DON as disrespectful to the resident's dignity. Facility documentation and staff interviews confirmed that the resident was secluded in the dining room and not treated with respect and dignity during the behavioral episode.