Failure to Maintain Resident Dignity and Respect
Penalty
Summary
Staff failed to treat three residents with dignity, as evidenced by multiple interviews, observations, and record reviews. One resident with severe cognitive impairment and a history of stroke and aphasia was repeatedly told by staff to chew and swallow his food, despite care plan instructions to avoid such directives. Staff were observed and reported to have taken away the resident's plate, rubbed his cheek in an aggressive manner, and used a mean tone when instructing him to eat. The speech therapist and physical therapist both confirmed witnessing inappropriate staff interactions, including frustration and aggressive verbal and physical cues, which made the resident feel 'disgusting.' The Director of Nursing acknowledged that telling the resident to swallow was a trigger and that staff should not touch the resident's cheek or plate. Another resident with intact cognition reported that staff on the third shift used their personal phones during work hours, making the resident feel undervalued and uncomfortable asking for help. Multiple staff interviews confirmed that personal phone use occurred during shifts, including during resident care and in hallways. The facility's cell phone policy prohibits personal phone use during working hours and in patient care areas, except for authorized business purposes, but staff and social services confirmed that the policy was not consistently followed, leading to resident dissatisfaction and irritation. A third resident, also with intact cognition and total incontinence, reported that the facility frequently ran out of appropriately sized incontinence briefs, resulting in the resident having to wear briefs that were too large or of a different type. Staff confirmed that supply shortages led to residents wearing incorrect sizes, which caused discomfort and skin issues. The staffing coordinator and Director of Nursing acknowledged the supply issues, with staff sometimes borrowing briefs from other rooms and residents being left without the correct size until new supplies arrived. The facility's policy requires staff to be trained on resident dignity and respect, but these incidents demonstrate a failure to uphold those standards.