Failure to Ensure Resident Dignity During Care and Discharge
Penalty
Summary
The facility failed to ensure the dignity of two residents as evidenced by staff actions and omissions. In the first instance, a cognitively intact resident with multiple medical diagnoses, including heart failure and diabetes, was reportedly treated roughly by the facility administrator, who took silverware from the resident's hand while eating and removed the resident from the dining area. The resident's personal belongings were packed without explanation, and the resident was transported away from the facility without being informed of the reason, causing confusion and distress. Staff reported that the resident's belongings were left on the ground outside, and the resident repeatedly asked why she was being removed, indicating a lack of communication and respect for her dignity. In the second instance, another resident who required assistance to prepare for dialysis activated the call light early in the morning but did not receive timely help. Two CNAs arrived shortly before the resident's scheduled transportation and hurriedly prepared him, resulting in a washcloth being left inside his incontinence brief. The resident became aware of an odor after dialysis, which was confirmed by both the dialysis nurse and the transportation driver, leading to feelings of humiliation. Upon return to the facility, staff discovered the washcloth during care, and the resident was visibly upset and requested to be left alone. These events demonstrate failures in providing dignified and attentive care to the residents involved.