Failure to Uphold Resident Dignity and Preferences
Penalty
Summary
The facility failed to uphold residents' rights to dignity and respect in two specific cases. In the first case, a resident with a history of bipolar disorder and mental illness, who was cognitively intact, was not addressed by their preferred nickname despite the family informing staff of this preference. The resident's care plan and medical record did not reflect the preferred name, and staff continued to address the resident by their last name. Observations confirmed that even after signs were placed in the resident's room indicating the preferred nickname, staff persisted in using the last name during interactions. In the second case, a resident with significant urinary and kidney conditions, including retention of urine, hydronephrosis, and obstructive uropathy, had an indwelling catheter. On multiple occasions, the resident's urinary drainage bag was observed to be uncovered and fully visible, positioned on the bed rail facing the doorway, without a privacy bag. Several staff members, including CNAs and the unit manager, acknowledged that the catheter bag should have been covered to maintain the resident's privacy and dignity, but this was not done. Both deficiencies were identified through direct observation, interviews with staff and family, and review of medical records and care plans. The facility's own policies emphasized resident-centered care and the importance of recognizing individual preferences, but these were not followed in the cases described, resulting in a failure to treat the residents with the dignity and respect required.