Resident Transported to Appointment Without Proper Personal Care or Attire
Penalty
Summary
A cognitively intact, bedbound resident with chronic pain, diabetes, and muscle weakness was transported to a physician appointment without being provided appropriate personal care and attire. The resident, who was dependent on staff for transfers and toileting and was incontinent of bowel and bladder, was taken to the appointment in a urine-soiled brief, wearing a hospital gown instead of her personal clothing, and without her hair being brushed. The resident reported feeling embarrassed and stated that she was not given the opportunity to communicate her needs before leaving for the appointment. Staff interviews revealed that the transportation schedule was made available to nurses daily, and it was the responsibility of the nursing staff to ensure residents were ready for their appointments. On the day of the incident, the nurse assigned to the resident instructed a nursing assistant to prepare the resident, but the nursing assistant did not provide the necessary personal care. The nurse observed that the resident was not properly dressed and did not have her hair brushed when the ambulance arrived but did not reschedule the appointment, resulting in the resident being sent out in an undignified state. The resident described the experience as distressing, noting that she was wheeled through a busy waiting room with her chest and shoulders exposed and feared she smelled of urine. The incident was confirmed through a grievance filed by the resident, and staff interviews corroborated that the resident was not provided with appropriate care or attire prior to leaving for the appointment.