Failure to Ensure Resident Dignity and Adequate Incontinence Supply
Penalty
Summary
The facility failed to ensure residents' dignity and rights by not providing incontinence supplies in the correct sizes and quantities, as well as by not preventing undignified interactions between residents. Multiple residents without cognitive impairment reported ongoing issues with access to appropriately sized incontinence briefs and pull-ups, with some residents forced to use incorrect sizes or go without supplies for extended periods. Staff interviews confirmed that supply distribution was restricted, with diapers stored in locked areas and limited quantities provided per shift, leading to shortages. The central supply and administrative staff acknowledged ongoing problems with supply management, including attempts to control inventory due to concerns about hoarding, but residents continued to report unmet needs. Additionally, the facility failed to prevent or address undignified verbal interactions among residents. Several residents and staff described incidents where one resident, with a history of mental illness and behavioral symptoms, verbally harassed and insulted other residents, including making derogatory comments about their weight and threatening statements. These behaviors were witnessed by other residents and staff, and in some cases, were not reported to or addressed by facility leadership. The affected residents generally reported feeling safe, but the incidents were recurrent and known to staff. The facility's policies regarding resident rights and dignity were requested but not provided during the survey. The combination of inadequate supply management for incontinence products and insufficient intervention in resident-to-resident verbal abuse resulted in a failure to uphold residents' rights to dignity, self-determination, and respectful treatment.