Failure to Maintain Resident Dignity and Respect During Care
Penalty
Summary
Facility staff failed to interact with residents in a kind and considerate manner, resulting in a lack of dignity and respect for at least two residents with moderate cognitive impairment. Interviews and clinical record reviews revealed that one resident reported being told by staff to urinate in bed and that staff would clean her up afterward. Another resident stated that an LPN did not treat him with dignity and respect, and staff interviews corroborated that complaints had been made about staff being gruff, rude, or not listening to residents. There were also reports that staff had withheld or removed call lights from residents, limiting their ability to request assistance. Multiple staff members, including CNAs and LPNs, confirmed hearing about or witnessing inappropriate comments and actions, such as instructing residents to be incontinent and delaying responses to call lights. Staff also reported that grievances and complaints about these behaviors had been brought to management, but no disciplinary actions were found in the personnel files of the staff involved. Documentation from staff meetings and performance evaluations indicated ongoing concerns about staff attitudes and interactions with residents. The Director of Nursing and Administrator acknowledged receiving complaints about staff behavior, including rough bedside manners and not providing call lights to residents. Despite these reports, investigations were unable to determine the specific staff responsible in some cases, and the issues persisted over time. Facility policy requires all staff to promote and maintain resident dignity, but the documented actions and inactions of staff failed to uphold this standard for the residents involved.