Failure to Honor Resident Rights in ADL Care and Personal Belongings Management
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity regarding Activities of Daily Living (ADL) care and the monitoring of personal belongings. One resident, who was severely cognitively impaired and dependent on staff for bathing, reported being bruised during ADL care when staff members attempted to provide a shower despite her repeated refusals. Staff interviews confirmed that the resident was resistive to care, held onto the bed rail, and expressed not wanting a particular CNA to assist her. Despite this, staff removed her fingers from the rail and proceeded with the shower, during which the resident became upset and physically grabbed a staff member. Facility policy and staff interviews indicated that residents should not be forced to receive care if they refuse, and refusals should be documented and reported to nursing staff, but an anonymous staff member reported that staff were told not to document refusals and to provide care regardless of resident wishes. Additionally, the facility failed to maintain accurate inventory lists of residents' personal belongings. Multiple residents reported missing personal items, such as a blanket and a purse, and interviews and record reviews revealed that inventory lists were either missing or not maintained in the residents' records. The Housekeeping Supervisor was unable to locate any documentation of residents' belongings, and it was noted that the previous supervisor was responsible for this task. Facility policy required that all personal belongings be listed in the resident's chart, but this was not being followed. These deficiencies were identified through interviews, observations, and record reviews, and were found to be in violation of facility policies regarding resident rights to dignity, respect, and the retention and use of personal possessions. The issues affected several residents with varying levels of cognitive impairment and medical conditions, including heart failure, stroke, hypertension, and diabetes.