Failure to Provide Dignity and Respect to Residents
Penalty
Summary
Staff failed to provide dignity and respect to two residents. For one resident with neuromuscular bladder dysfunction, depression, and nicotine dependence, a CNA made an inappropriate gesture by lifting her own breasts over her shirt in front of the resident during care. The CNA admitted to making the gesture in an attempt to be funny, but the resident did not find it humorous and reported the incident occurred about a month prior to the interview. For another resident with severe cognitive impairment, memory problems, and total dependence for activities of daily living, staff did not interact with or ask the resident before placing a clothing protector on her in the dining room. Additionally, a CNA referred to the resident as the "only true feed" in the dining room, a term acknowledged by the CNA as disrespectful. Both staff members confirmed their actions during interviews. Facility policy requires residents to be treated with respect and dignity, but these actions did not meet that standard.
Plan Of Correction
F557 The facility failed to maintain the dignity of residents; A) a STNA #206 referred to residents requiring assistance with food and fluid intake as "Feeds," B) a STNA #222 applied a clothing protector on resident #21 prior to asking permission to do so and waiting for a reply, and, as well as C) a STNA #240 made an inappropriate gesture in regard to breasts in the presence of resident #22. Step 1: The facility DON immediately... A) Educated the STNA #206 on the inappropriateness of referring to residents in terms of needs, diagnoses or other identifiable qualifiers, emphasizing the importance of using more appropriate terminology such as "residents requiring assistance with..." on 6/3/25. B) Educated STNA #222 on the need to ask and wait for reply prior to applying items such as clothing protectors to residents and if resident is unable to reply or understand on 6/3/25, IDT to discuss with resident representative and ensure stated desires are care planned. Completed on 6/27/25. C) SRI opened and investigation initiated. Completed on 6/10/25. Step 2: To identify other residents that have the potential to be affected... A) DON or designee reviewed current residents that require assistance with oral intake. B) DON or designee reviewed current non-verbal and/or cognitively impaired residents that might use clothing protectors during meals. C) Resident interviews with interview-able residents and skin sweeps on non-interview-able residents completed with no negative findings (R/T SRI). Completed on 6/27/25. Step 3: To prevent this from recurring... A) DON or designee will educate staff on the inappropriateness of referring to residents in terms of needs, diagnoses or other identifiable qualifiers, emphasizing the importance of using more appropriate terminology such as "residents requiring assistance with..." Completed on 7/11/25. B) DON or designee will educate staff on asking residents permission and waiting for a response prior to applying a clothing protector and for non-verbal residents to verify use on care profile or care plan. Completed on 7/11/25, for non-verbal and/or residents that are unable to respond the DON or designee will contact the residents' responsible party to discuss use of clothing protectors during meals and update the residents' care plans and care profile with responsible party's desires related to the use of clothing protectors. Completed 6/27/25. C) LNHA educated current staff on the Abuse, Neglect, and Misappropriation Policy and Procedure. Completed on 6/7/25. STNA #240 was educated by the facility Staffing Coordinator on 6/16/25 prior to returning to work. Step 4: To monitor and maintain ongoing compliance... A) DON or designee will audit 5 staff members per week x4 weeks then monthly x2 months for appropriate responses. B) DON or designee will review new admissions for ability to determine desire for clothing protector use and if non-verbal or cognitively impaired will discuss with responsible party then update care plan and profile as indicated in addition to auditing 3 non-verbal/cognitively impaired residents weekly x4 weeks then monthly x2 months for clothing protector use in relationship to care planned desires. C) DON or designee will interview 3 residents per week x4 weeks then monthly x2 months to ensure appropriate staff behavior while providing care or in resident areas. Audits will begin 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. F565 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure that resident concerns were addressed in a timely manner or resolved affecting resident #24, #35, and #29. Step 1: Concerns that were not addressed for residents #24, #35, and #29 were written on Concern forms by NHA and given to appropriate manager for follow-up. This will be completed by 6/30/25. Step 2: Resident Council Minutes were audited back six months by NHA to ascertain any concerns not addressed on 6/30/25. Concern forms were completed and given to appropriate department manager for resolution. Step 3: LED, Life Enrichment staff, and all department managers will be educated by LNHA on proper follow-up of Resident Council concerns, i.e., proper documentation of the following: education provided, equipment needed, replacement of items, etc. This will be completed by 6/30/25. Step 4: To monitor and