Failure to Honor Resident's Care Preferences and Dignity
Penalty
Summary
The facility failed to honor a resident's right to self-determination and dignity by not supporting their expressed preference to avoid care from a specific Certified Nurse Aide (CNA). The resident, who had intact cognition and required total assistance with activities of daily living due to multiple medical diagnoses, filed a grievance in January 2025 stating that some CNAs, particularly one, were too strong and manhandled them, causing discomfort due to sensitive legs. Despite this grievance and repeated verbal complaints to facility leadership, there was no documented evidence that the resident's care plan was updated to reflect their preference to not receive care from the identified CNA. The CNA in question subsequently provided care to the resident, waking them early in the morning and performing care after the resident refused, which the resident again described as manhandling. Interviews with facility staff, including the Director of Nursing (DON), Administrator, and Director of Social Services, confirmed awareness of the resident's complaints and preference. However, the DON admitted that instructions to avoid assigning the CNA to the resident were given verbally and not documented in the care plan or communicated through the Kardex Care Guide. The facility's policy required care to be provided with resident consent and according to the care plan, but the lack of documentation and communication led to the resident's preferences not being honored, resulting in the deficiency.