Failure to Protect Resident Rights and Dignity During ADL Care and Grievance Process
Penalty
Summary
A resident with chronic kidney disease, type 2 diabetes, left-sided muscle weakness/paralysis, cognitive communication deficit, major depressive disorder, and a history of homelessness was admitted to the facility. The resident had moderate cognitive impairment and was frequently incontinent of bowel, requiring assistance with activities of daily living (ADLs). The care plan for the resident included interventions for medication and pharmacy review related to major depression, but did not address ADL care or psychosocial needs in detail. The resident filed a grievance stating that a CNA did not change them when requested, resulting in the resident remaining in soiled clothing during mealtime. Multiple interviews and documentation confirmed that the resident was not changed in a timely manner, and the CNA assigned to the resident was removed from the hall following the complaint. The resident and external care providers reported that the resident appeared disheveled, had lost weight, and expressed fear of retaliation after making the grievance. The resident also reported being treated roughly and being left in soiled clothing for extended periods, which caused psychosocial distress. Following the grievance, the facility updated the resident's care plan to include statements about the resident making false allegations and exhibiting maladaptive behavioral symptoms, despite no documented behavioral issues prior to this event. The care plan revision was made on the same day the facility received a complaint from an external provider. Interviews with staff indicated that the resident's concerns were not fully addressed, and the care plan was amended in a way that could be perceived as punitive after the resident exercised their right to file a grievance.