Failure to Maintain Resident Dignity and Respect
Penalty
Summary
Facility staff failed to treat residents with dignity and respect in several instances. For one resident with severe cognitive impairment and limited mobility, staff did not maintain the cleanliness of his wheelchair as required by his care plan. The wheelchair and its cushion were observed to have a strong urine odor, visible crumbs, and stains, and family members had repeatedly expressed concerns about the lack of cleaning. Staff interviews confirmed that the cleaning schedule was not being followed, and documentation showed the wheelchair had not been cleaned that week. In another case, a CNA used an expletive to describe a resident's behavior in a public area near other residents and staff. The resident in question had severe cognitive impairment and exhibited physical behavioral symptoms. The facility's policy required staff to treat residents with respect and dignity, but the CNA's public comment violated this expectation. Both the DON and the Administrator acknowledged that such remarks were inappropriate and not in line with facility standards. A third resident, also with severe cognitive impairment and a history of falls, had signs posted in his room and on his walker instructing him to use the call light and ask for help before getting up. These signs were placed without consulting the resident, who found them insulting and irritating. The resident reported that he had used the call light before his falls but staff did not respond promptly, leading him to attempt to use the bathroom independently. Progress notes did not document any discussion with the resident or his representative regarding the addition of these interventions.