Failure to Maintain Resident Dignity Due to Persistent Urine Odor
Penalty
Summary
The facility failed to promote dignity for two residents sharing a room, as evidenced by a persistent and strong urine odor in their shared bedroom. Observations revealed a soiled diaper left on top of a potty chair since the morning, which had not been cleaned or removed by staff. Both residents were alert and able to communicate, with one resident expressing that the constant urine smell made her feel undignified and that staff did not care about maintaining a clean environment. The other resident reported feeling uncomfortable and likened the experience to being inside a bathroom, stating that there was no dignity in the situation. Staff interviews confirmed the presence of the strong urine odor and the soiled brief, with a CNA acknowledging that the room often smelled this way and a licensed nurse describing the situation as undignified. The Social Service Director and Director of Nursing both agreed that the environment was not dignified and that the room should be kept clean to promote residents' dignity and quality of life. The facility's own policies require care that enhances residents' well-being and prohibits practices that compromise dignity, but these standards were not upheld in this instance.