Failure to Maintain Resident Dignity During Care, Noise, and Staff Interactions
Penalty
Summary
Facility staff failed to treat multiple residents with dignity and respect as required by the facility’s Dignity and Respect policy. One resident with dementia, anxiety disorder, chronic pain, moderate cognitive impairment, and total dependence on staff for mobility, transfers, toileting, and hygiene was observed being transferred from a wheelchair to bed with a mechanical lift and then repositioned roughly. After the transfer, CNAs used a reusable incontinence pad to pull the resident down in bed, causing the incontinence brief to remain in place and pinch the resident’s groin. When the resident yelled out, “Stop, you’re hurting me!”, one CNA told the resident to “hold on” and “you’re fine” and continued care without stopping to relieve the discomfort or acknowledge the pain. The same CNA later stated that the resident “always complained.” The same resident and the resident’s spouse reported additional incidents involving staff behavior that did not maintain dignity. The spouse stated that the CNA involved in the transfer was rough and always in a hurry, and described a prior episode during a transfer to a shower chair where the resident yelled out in pain while the CNA continued positioning, telling the resident to “hold on a minute.” The spouse also reported that the resident became upset and anxious when the Director of QAPI confronted a CNA in the dining room, placing hands on hips and repeatedly telling the CNA to get back to work while the CNA was on a lunch break eating with residents. This interaction occurred in front of residents, family members, and visitors and was described as unprofessional and upsetting to the resident. Another resident, cognitively intact with a documented hearing deficit and a care plan requiring staff to allow adequate time to respond and reduce environmental noise, reported that staff did not treat them with respect at night. The resident stated that night shift staff played music loudly enough to keep them awake and refused to turn it down, telling the resident it could not be lowered because other residents enjoyed it. Additionally, staff, including a CMT, were reported to have squirted each other with water in the dining room on a busy, stressful day. The resident with anxiety became upset and told staff to stop, but a CMT approached, handed the resident a squirter, and encouraged the resident to “shoot someone with it,” which the resident did not want to do and did not participate in. The DON later stated she was unaware of the loud music at night and the water-squirting incidents, but her stated expectation was that staff treat residents with dignity and respect and not be rough or rushed when providing care.
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