Failure to Provide Dignified Care and Respect Resident Privacy
Penalty
Summary
Facility staff failed to treat three residents with dignity and respect as required by policy. One resident, who had a history of hemiplegia, hemiparesis, chronic heart failure, and chronic pain, was dependent on staff for toileting and hygiene. On the day of the incident, the resident experienced incontinence while preparing to attend church and requested assistance with hygiene. Staff informed the resident that if incontinence care was provided, the resident would not be able to attend church, leading the resident to attend the service in a soiled brief. The Manager on Duty was not informed of the incident until after lunch, and incontinence care had still not been provided by early afternoon. Multiple interviews confirmed that the resident and their representative reported the incident, and staff acknowledged the failure to provide timely care. Additionally, the facility failed to ensure privacy and dignity for two other residents sharing a room. During an observation, a staff member entered the shared room without knocking or announcing herself, despite the facility's policy requiring staff to knock and request permission before entering any resident's room. The staff member believed that knocking was unnecessary if the door was open, a misunderstanding not supported by facility leadership or policy. Interviews with facility leadership confirmed that the expectation was for staff to always knock or announce themselves before entering, regardless of whether the door was open. These incidents demonstrate that staff did not follow established policies designed to protect resident dignity, including prompt response to requests for incontinence care and respecting privacy by knocking before entering resident rooms. The failures were confirmed through interviews with residents, their representatives, and facility staff, as well as review of facility policies and grievance documentation.