F0550

D

Failure to Honor Resident Dignity, ADL Needs, and Nighttime Preferences

Hagerstown, Maryland Survey Completed on 01-29-2026

Penalty

Fine: $21,665

Summary

Facility staff failed to honor residents’ rights to dignity and self-determination by not addressing one resident’s ADL needs in a timely manner and by disregarding another resident’s clearly documented preference not to be disturbed during specified nighttime hours. During a unit tour, a resident later identified as Resident #7 was observed at the nurses’ station repeatedly and loudly requesting assistance to use the bathroom, stating they had stomach pain and did not want to soil themselves. An LPN at the nurses’ station verbally acknowledged that the resident needed a lift and should not stand, but then continued medication preparation and administration, later walking around the station and sitting at the desk on the phone without providing assistance, attempting to soothe the resident, or arranging for timely toileting.

The observations showed that Resident #7 continued to call out for help for an extended period, from at least 11:03 AM until 11:15 AM, with visitors also present and concerned, while the LPN did not respond to the resident’s expressed need for toileting and relief of stomach pain. The resident’s care plan included that the resident was known to fixate on going to the bathroom and might sit on the commode without voiding, but the DON acknowledged that this did not excuse the lack of response from the nurse on the day of observation. ADL care was eventually provided at 11:24 AM by another staff member, an RN working in the role of a GNA, who took the resident to their room and placed them on the toilet, indicating a significant delay between the resident’s initial requests and the provision of toileting assistance.

In a separate incident, the facility did not respect Resident #4’s documented preference and physician’s order not to be awakened between 11:00 PM and 7:00 AM. The resident had no cognitive impairment per a quarterly MDS and was able to voice needs, and the care plan and a physician’s order both specified that the resident was not to be woken during those hours. Despite this, an RN entered the resident’s room around 6:15 AM while the resident was asleep, pulled down the covers, and inspected the resident’s colostomy bag. Additionally, the Treatment Administration Record contained staff-entered orders scheduled between 11:00 PM and 7:00 AM, including turning and repositioning, catheter care, and administration of fluids, which required staff to wake the resident during the period they had expressly requested and been ordered not to be disturbed. The resident reported wanting staff to empty the colostomy bag before bedtime and stated being fully capable of requesting help when needed, and the unit manager confirmed awareness of the resident’s preference not to be awakened at night.