Failure to Honor Resident Rights and Care Plan During Shower
Penalty
Summary
The facility failed to maintain the rights and dignity of a resident with late onset Alzheimer's disease who had moderately impaired cognition. The resident was known to be resistant to care, including showering and bathing, and had a care plan in place directing staff to use alternative approaches such as postponing care, trying again later, or notifying a nurse if resistance occurred. Despite these interventions, staff proceeded to provide a shower when the resident was visibly resistant and combative, resulting in the resident receiving a skin tear during the process. Staff interviews confirmed that the resident was fighting and cussing at staff, and that the care plan was not followed as required. Documentation and interviews revealed that the staff did not attempt alternative approaches or postpone the shower as directed by the care plan. Instead, they continued with the shower despite the resident's resistance, and only after the resident became combative did the nurse instruct staff to return the resident to their room. The Director of Nursing and Administrator both confirmed that the staff did not follow the person-centered care plan, which required attempts to identify the cause of resistance and to try care at a different time or with different staff. Facility policies also required residents to be treated with dignity and to have the right to refuse care, which was not upheld in this incident.