Failure to Maintain Resident Dignity During Incontinence Care
Penalty
Summary
The deficiency involves a failure to ensure a resident’s right to dignity and self-determination during incontinence care. The resident was admitted with orthostatic hypotension and heart failure and had an admission MDS BIMS score of 15, indicating intact cognition. According to a facility incident report, the resident reported that a male CNA entered his room and pulled down his underwear or pants while he was in bed, with the resident later clarifying that he was woken up by the CNA attempting to pull his underwear down. The resident stated that the CNA did not announce himself, did not knock on the door, and that he felt tugging at his hip while he was asleep. The resident reported that the CNA told him he had to take his underwear off and that the CNA was trying to remove his underwear to check for incontinence, but the resident denied being touched in a sexual manner. The incident reports and subsequent interview with the resident consistently described that the CNA attempted to provide incontinence care without first waking the resident or obtaining his permission, and without announcing his presence or knocking before entering the room. These actions failed to honor the resident’s right to be treated with dignity and to exercise control over his personal care.
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