Failure to Offer Resident Choice During Shower Resulting in Psychological Distress
Penalty
Summary
Staff failed to honor a resident's right to self-determination and choice regarding personal care. On the morning of 3/21/25, two CNAs entered the room of a resident with spinal stenosis and discogenic pain and informed her she would be receiving a shower, without offering her a choice or seeking her consent. During the transfer from bed to shower, the resident experienced incontinence, requiring her to be cleaned and then placed in a Hoyer lift for transfer to the shower chair. The resident reported feeling upset and embarrassed during the incident, especially as the CNAs argued about operating the lift. A roommate, who was cognitively intact, witnessed the event and described the resident being yanked from bed and hoisted up. Interviews with staff confirmed that the resident was alert, oriented, and capable of expressing her preferences, and that it was important to explain care procedures to her beforehand. The Social Service Director also confirmed a complaint from the resident's son regarding the incident. Facility policy requires that residents be informed in advance of care, have the right to refuse or discontinue treatment, and that staff are educated on resident rights, including the right to choose schedules and activities. Despite these policies, the resident was not given the opportunity to exercise her right to refuse or choose her care at the time of the incident.