Failure to Maintain Resident Dignity During Meal and Incontinence Care
Penalty
Summary
The facility failed to ensure that two residents were treated with respect and dignity, and that their care promoted or enhanced their quality of life. One resident, who required substantial assistance with eating and was unable to communicate effectively, was observed sitting at a dining table during lunch while other residents were served, ate, and left the area. This resident was not served her meal along with the others, and staff interviews confirmed that her tray was intentionally prepared last because she required feeding assistance. The LPN on duty was unaware that the resident had not been served, despite all other residents at the table having completed their meals. Another resident, with severe cognitive impairment and a history of incontinence, was observed multiple times in bed with a soiled brief and a strong odor of feces in the room. Despite these observations, staff attempted to feed the resident breakfast without providing incontinence care beforehand. The LPN confirmed that the resident should have received incontinence care prior to being served breakfast and acknowledged that the lack of care could have contributed to the resident's refusal to eat. The DON also confirmed that incontinence care should have been provided before attempting to feed the resident.