Failure to Promote Resident Dignity During Care and Room Transfers
Penalty
Summary
The facility failed to provide an environment that promoted and enhanced residents' dignity for three residents. One resident reported that a CNA rushed them off the toilet while they were attempting to have a bowel movement, using a raised voice and displaying a negative attitude. The resident described feeling belittled and scared, and stated that no one followed up with them about the incident. Review of the resident's care plan confirmed they required one-person assistance with toileting and transfers, and documentation showed the resident was cognitively intact. There was no evidence in the medical record of any nursing, social services, or staff documentation or follow-up regarding the incident. Another resident described an incident where a CNA abruptly interrupted their phone conversation, accused them of violating privacy rights, and stated they would not provide care for the rest of the night. The resident became upset and cried, and two nurses intervened, apologized, and reassured the resident. The resident's sister came to the facility to provide support. The resident reported that the CNA had not provided care to them since the incident. The resident was alert and oriented at the time of the interview. A third resident was moved to another room after being diagnosed with C. diff. The resident did not want to move and became visibly upset, crying and yelling during the transfer. The administrator and supervisor insisted on the move, and maintenance staff moved the resident in her bed while other staff observed. The resident reported feeling humiliated and stated that staff did not treat her with respect and dignity. Interviews with staff confirmed that social work was not involved prior to the move, and the infection control nurse later stated that the move was not handled appropriately from an infection control perspective. The resident remained upset until she was allowed to return to her original room.