Failure to Maintain Resident Dignity by Not Assisting with Clothing Change
Penalty
Summary
Staff failed to provide care that promoted a resident's dignity by not assisting a dependent resident to change out of a heavily soiled shirt, which the resident continued to wear throughout the day in the presence of other residents and visitors. The resident, who had severe cognitive impairment, non-Alzheimer's dementia, depression, hypertension, and was always incontinent of urine, required maximum assistance with dressing and personal hygiene. Observations showed the resident wearing a white T-shirt with multiple large and small brown stains on the chest area from early morning through the afternoon, despite being present in common areas and during meals with other residents and visitors. Multiple staff interactions occurred throughout the morning, including the use of mechanical stand lifts for incontinence care, but the resident remained in the same soiled clothing after each care episode. Staff interviews confirmed that the resident was cooperative with care and that staff were expected to assist with clothing changes as needed. Despite these expectations and the resident's dependence on staff for dressing and hygiene, the resident was not changed out of the soiled shirt for several hours.