Failure to Maintain Resident Dignity and Timely Response to Grievance
Penalty
Summary
A resident with osteoarthritis, muscle weakness, and significant limitations in activities of daily living (ADLs) required staff assistance for personal care, including dressing, bathing, and mobility. During a night shift, a CNA assisted the resident after a bedpan incident resulted in soiled bedding and gown. While changing the resident and the bed linens, the CNA removed the resident's hospital gown and left the resident exposed and uncovered in bed. The resident requested to be covered due to feeling cold, but the CNA did not respond, left the resident exposed, and exited the room to get supplies. The resident reported feeling disrespected, undignified, and dehumanized by this experience. The resident communicated the incident to multiple staff members the following morning, including a nurse, rehabilitation staff, and later to the unit manager and social worker. Despite these reports, there was a significant delay in staff response and investigation. The resident was not promptly interviewed about the incident, and the grievance process was not initiated in a timely manner. The CNA involved returned to the resident's room later that day, despite the resident's expressed wishes not to receive care from that CNA, and only left after being told by the resident about the complaint. Interviews with staff revealed confusion and lack of clarity regarding the grievance process and timely follow-up. The social worker did not return to the resident until several hours after the initial report, and the grievance form was not processed or followed up on until brought to the attention of surveyors. The resident did not receive communication about the outcome of the complaint until much later, and staff failed to ensure the resident's dignity and respect during personal care, as well as a timely and appropriate response to the resident's concerns.