Failure to Maintain Resident Dignity During Care, Medication Pass, and Care Plan Meeting
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact resident was treated with dignity and respect during care interactions and a care plan meeting. The resident, an adult with Meniere's Disease, PTSD, and Acute Metabolic Acidosis, reported that on 01/09/2026 an LPN responded to her call light after a delay of about 10 minutes, during which she had requested assistance to the bedside commode and medication for stomach, gas, and chest pain. The resident stated that the CNA who assisted her was a tall Black male who did not speak, did not provide instructions or guidance during the transfer, did not use a gait belt, and left the room despite her request that he stay nearby. She reported that when the LPN arrived, the nurse appeared very angry, slammed the medication cup onto the bedside table, and used profanity, telling her to “shut the f*** up” and referring to her as a “f***ing problem” and “that bitch” while speaking with the CNA outside the room. The resident demonstrated to surveyors how the pills were slammed down and described feeling afraid she would fall during the transfer. During a care plan meeting held in the resident’s room with the Administrator, DON, therapy staff, and nursing staff, the resident reported that the Administrator told her and her husband that “this is not a hotel” and threatened that she and her husband would be thrown out and banned from the facility if they continued to voice grievances or if her husband kept “screaming” at staff. The resident denied screaming at staff and expressed frustration about not receiving daily baths as requested and documented on a sign in her room, and about therapy being discontinued after she refused one session due to claustrophobia related to using the elevator. The Administrator acknowledged to surveyors that he may have commented that the facility was not a hotel and discussed the resident’s food choices in relation to his personal experience with diabetes, while denying that he threatened eviction or made derogatory remarks about her appearance. The CNA confirmed witnessing the LPN being rude and lacking professionalism toward the resident, though he could not recall exact words, while the LPN denied using profanity and attributed the resident’s behavior to anxiety and PTSD.
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