Failure to Provide Dignified and Hygienic Discharge for Dependent Resident
Penalty
Summary
A deficiency occurred when a female resident with end stage renal disease, acute kidney failure, protein-calorie malnutrition, hypertensive heart and chronic kidney disease, cognitive communication deficit, and aphasia was not provided with appropriate personal grooming and hygiene prior to her discharge to the hospital. The resident was totally dependent on staff for bathing and required moderate assistance for dressing, as documented in her care plan. On the night of her discharge, the resident was sent to the hospital in dirty clothes and a soiled brief, with unclean skin and an odor, as reported by hospital staff upon her arrival. Interviews with hospital staff confirmed that the resident arrived in an unkempt state, requiring immediate cleaning and a change of clothing and brief. Family members also reported ongoing issues with the resident's grooming during her stay, including tangled hair that eventually had to be cut, unbrushed teeth, and frequent observations of the resident in soiled briefs and dirty gowns. Family members stated they had to request clean gowns from staff multiple times per week, though no formal complaint was filed with the facility. Interviews with the facility's CNAs and nursing staff revealed that none of the CNAs on duty during the relevant shift recalled assisting the resident with preparation for discharge or were aware of her transfer to the hospital. The RN responsible for the discharge stated that a CNA should have changed the resident, but could not recall who performed the task. The DON and Administrator both stated that it was their expectation that residents be clean and appropriately dressed when discharged, but neither was aware of the incident until after the fact. Review of the facility's policy confirmed the resident's right to dignity and proper care.