Failure to Ensure Resident Dignity and Respect in Care and Environment
Penalty
Summary
The facility failed to provide a respectful and dignified environment for three residents, as evidenced by multiple observations and interviews. One resident, who was cognitively intact and dependent on staff for toileting and mobility, was not offered meal choices according to her preferences. Staff delivered an incorrect meal and, without asking the resident for her preference, substituted it with a food item not listed on the menu or alternative menu. The resident reported that she is never asked what she would like to eat and is typically given whatever is available, rather than being provided with options. Another resident with bowel incontinence and frequent diarrhea was observed multiple times in a room with a strong odor of feces and urine, and with visibly soiled sheets and floors. The resident confirmed that his sheets had been soiled since the previous night. Observations over several days revealed persistent dried feces on the bed sheets, floor, and bathroom surfaces. Staff interviews confirmed awareness of the soiled conditions, and the CNA job description included maintaining a clean and pleasant environment, which was not upheld in this case. A third resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was found lying in bed without an incontinence product and with pants pulled down around her ankles. This condition persisted during subsequent observations until the DON intervened to provide care and clothing. The resident expressed feeling cold during this time. Facility policy requires residents to be treated with dignity and respect, which was not observed in these instances.