Failure to Honor Resident's Right to Dignity and Self-Determination During Care
Penalty
Summary
A resident with hemiplegia following a stroke, major depressive disorder, reduced mobility, and aphasia was involved in an incident where their right to dignity and self-determination was not honored. The resident was severely cognitively impaired, rarely or never understood by others, but able to understand others and communicate needs through gestures. The care plan specified the need to avoid restraints, respect the resident's decisions, and allow for alternative communication methods. On the day of the incident, the resident refused to get out of bed multiple times, verbally and physically indicating their refusal. Despite the resident's clear refusal, a registered nurse (RN) and a certified nurse aide (CNA) entered the resident's room to get the resident up for lunch. The RN insisted that the resident needed to get up, and when the resident resisted by grabbing the bed rail and flailing their arm, the RN forcibly removed the resident's hand from the rail and held the resident's arms down. This resulted in a moon-shaped skin tear on the resident's left arm. The CNA reported that the RN did not offer the resident the option to remain in bed and did not respect the resident's expressed wishes. Interviews and documentation confirmed that the resident was upset by the encounter, indicated pain from the injury, and expressed a desire for the RN to stay out of their room. The administrator acknowledged that the resident had the right to remain in bed and that the RN should have walked away, as the resident was safe. The incident was identified as a failure to treat the resident with dignity and respect, and to honor their right to self-determination and communication.