Failure to Honor Resident Dignity and Rights
Penalty
Summary
The facility failed to honor a resident's right to dignity and self-determination in two separate incidents. In the first incident, a resident with chronic pain and dementia, who was moderately cognitively impaired and dependent on staff for bathing and toileting, requested that a nursing assistant stop a shower due to being handled roughly. Despite the resident's repeated requests to stop and expressions of discomfort, the nursing assistant continued with the shower and did not report the incident to supervisory staff. The resident later expressed fear of the nursing assistant and felt that his concerns were not being heard by staff. In the second incident, another resident with severe cognitive impairment and an indwelling catheter was observed multiple times with his urine collection bag visible from the hallway, lacking a privacy or dignity cover. The urine in the collection bag was visible to staff, visitors, and other residents passing by. Staff interviews confirmed that the privacy cover was not in place following the resident's return from a urology procedure, and that staff had not noticed or addressed the missing cover during their shifts. Both incidents demonstrate failures to maintain resident dignity and respect resident rights, as staff did not respond appropriately to resident requests or ensure privacy measures were in place. These deficiencies were identified through observations, record reviews, and interviews with residents, staff, and family members.