Failure to Maintain Resident Dignity and Provide Timely Incontinence Care
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were treated with dignity and respect, as required by policy and regulation. One resident with a history of altered mental status, muscle weakness, stroke, and bowel and bladder incontinence was observed in the dining room for several hours with a strong odor of bowel incontinence, in the presence of other residents. Documentation showed the resident required extensive assistance with toileting and hygiene, and was to be checked and changed every two to four hours or as needed. However, there was no evidence the resident received incontinence care at appropriate intervals, and when finally assisted, was found with a saturated brief and reddened buttocks. Multiple residents, including the resident in question, were observed wearing hospital gowns in public areas such as the dining room and hallways, rather than their own clothing, contrary to facility policy which encourages residents to dress in their own clothes to promote dignity. Staff interviews confirmed that many residents did not have their own clothes and routinely wore hospital gowns. Observations also noted that several residents were in hospital gowns or pajamas during meal times and while in common areas. Additionally, staff interactions with the resident were not respectful. When the resident requested to return to their room, a CNA responded by yelling in a loud, demeaning tone, instructing the resident to wait for dinner, and another staff member also loudly denied the request. The DON later acknowledged that it was not acceptable for staff to yell at residents and that residents should be able to return to their rooms if they wish, as the facility is their home.