Failure to Ensure Resident Dignity and Respect During Nighttime Care
Penalty
Summary
Staff failed to treat a cognitively intact resident with dignity and respect during care, as evidenced by an incident that occurred during the night following the resident's admission after a week-long hospitalization. The resident, who had diagnoses including Chronic Kidney Disease, Osteoarthritis, and Sjogren Syndrome, reported that while she was sleeping, a nurse entered her dark room without announcing themselves, pulled her blankets off, and attempted to remove her undergarments for a skin assessment. The resident was startled, attempted to resist, and ultimately had her underwear ripped during the encounter. The staff member did not provide any explanation or attempt to awaken the resident prior to initiating the assessment, which left the resident feeling violated and unsafe. The resident reported the incident to the Social Services (SS) designee during a routine post-admission assessment. She described feeling so unsafe after the event that she placed her walker in front of her door for security and experienced incontinence due to fear. The resident also expressed confusion and distress over the lack of communication and the manner in which the assessment was conducted. Despite being told by the SS designee that the staff member would not have further contact with her, the same nurse subsequently administered medications to the resident on multiple occasions after the grievance was filed. Interviews with staff confirmed that the incident involved a night shift nurse performing a skin assessment without proper communication or consent, and that the resident's concerns about exposure and feeling violated were not fully relayed or addressed by staff. The facility's records and interviews corroborated that the resident's rights to dignity, respect, and self-determination were not upheld during the care provided, as required by the facility's Resident Rights policy.