Failure to Maintain Resident Dignity and Respect During Care Interactions
Penalty
Summary
Surveyors identified a failure to maintain resident dignity for a cognitively intact resident with quadriplegia and generalized muscle weakness who required assistance with personal care. The resident’s MDS documented a BIMS score of 15, indicating no cognitive impairment. On the observed date and time, a CNA (Staff C) left this resident in bed wearing only a brief, with no sheets or clothing. Staff C left the room and went down the hall to another room, then continued other tasks. During this period, the Activities Director entered the room to deliver mail while the resident remained uncovered. The resident subsequently activated the call light, reporting that staff had left to get linen and that he felt uncomfortable and that his dignity was not respected while lying in bed without a sheet. Staff did not return to cover him until several minutes later, at which time the resident was observed with a blanket on. The resident stated that it usually did not take that long for staff to return to cover him, which was why he used the call light. In a later interview, Staff C acknowledged working that morning, giving showers, and forgetting to put sheets on the resident’s bed. She stated she believed she was not supposed to have a bottom sheet on the air mattress and reported that when she returned to answer the call light, the resident asked to have the blanket put over him. Staff C stated she apologized to the resident and said she had gotten sidetracked. The facility’s dignity policy in effect at the time stated that it was the practice of the facility to protect and promote resident rights, treat each resident with respect and dignity, and maintain or enhance quality of life by recognizing individuality and maintaining privacy. Surveyors also identified a dignity-related concern involving another resident with moderate cognitive impairment (BIMS score of 08) and diagnoses including hemiplegia, diabetes, and depression, who was totally dependent on staff for personal hygiene and dressing. This resident reported that a CNA (Staff P) recently slapped her upper leg while putting her feet back up in bed after noticing her attempting to get out of bed. The resident stated that the CNA was very mean verbally, yelled at her, lifted her feet, put them back in bed, tapped her upper leg, and that she then told the CNA to get out of her room. In a subsequent interview, Staff P stated she assisted the resident back into bed when she saw her trying to get out, was focused on safety because the resident could not walk on her own, and denied touching the resident’s upper leg in the manner described. The facility’s Abuse Prevention policy defined mistreatment as inappropriate treatment or exploitation of a resident and stated that the facility is committed to protecting residents from abuse by anyone.
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