Failure to Honor Resident Dignity and Rights
Penalty
Summary
A resident with paraplegia and a history of major depressive disorder was admitted to the facility and was cognitively intact, as evidenced by a BIMS score of 15/15. The resident had previously been involved in an incident where he accidentally bumped into another resident with his electric wheelchair, resulting in no injury but some pain. Following this incident, the facility restricted his use of the electric wheelchair within the building, allowing him to use it only when leaving the facility. The resident expressed that other residents were not similarly restricted after incidents, and he felt targeted and unfairly treated. Staff interviews confirmed that the resident had not been given a second chance to use his electric wheelchair inside the facility, and no education or interventions were provided to address the incident or prevent recurrence. The resident repeatedly voiced feelings of anxiety, frustration, and fear of retaliation or discharge due to the way management handled his situation. He reported that his requests, such as not having the DON present at his care conference, were disregarded by the former NHA, who insisted on the DON's attendance despite the resident's objections. Multiple staff members and the facility ombudsman corroborated that the resident felt disrespected, bullied, and that his rights were not honored. The resident also experienced additional distress when required to use a large orange flag on his wheelchair against his wishes and when his television access was disrupted without timely resolution from management. Documentation and interviews revealed that the facility failed to maintain the resident's dignity and respect his rights to self-determination and participation in care planning. Staff did not document or communicate the resident's grievances or emotional distress to management or the social worker, and interventions to establish a trusting relationship and maintain a non-threatening environment were not effectively implemented. The facility's own policies on resident dignity and rights were not followed, as the resident's preferences and autonomy were repeatedly overridden by management decisions.