Failure to Honor Resident’s Right to Refuse Care and Maintain Dignity During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that care and services were provided with respect and dignity and in accordance with a resident’s right to refuse care. Facility policy on Resident Mistreatment, Neglect and Abuse Prohibition states that the facility is committed to protecting each resident’s physical and emotional well-being and to fostering dignified treatment, respect, and compassion. Resident #999, who was cognitively intact per a recent MDS (BIMS score 15) and care planned for occasional refusal of care and combativeness, reported that while he was sleeping soundly, a CNA woke him to change him. He asked the CNA to wait 30 minutes, but she refused, stating she had to change him immediately. After he continued to refuse, the CNA left and returned with another CNA and a nurse. According to the resident, the nurse and CNAs told him he was wet, filthy, and lying in his own urine and that they needed to change him due to a change of shift. He stated that although he believed they could have waited as he requested, the staff proceeded, with two staff on one side and one on the other, and began holding him down while he yelled, “No. Stop, stop, stop.” He reported feeling helpless and angry that staff proceeded against his wishes and that he sustained a skin tear to his left hand, which the nurse bandaged. The clinical record documented that he required substantial/maximal assistance with toileting and hygiene and that his care plan directed staff to value his input, ensure safety, and re-approach later if he was resistive to care, as well as to honor his preferences and use a calming approach. Nursing documentation and staff statements confirmed that the resident had refused incontinence care during the night in question. An RN note recorded that the CNA reported the resident was refusing care and to be changed, and that when the nurse spoke with him, he became argumentative about concerns over skin breakdown, then stated, “do what you will, I don’t care,” after which care was provided and his brief was found saturated with urine and feces. Staff statements from an LPN and CNAs indicated that the resident initially declined care, was educated about skin concerns, and alternated between saying yes and no while they proceeded to roll and clean him, with the LPN placing his hands on the resident’s hips and back while CNAs worked. Staff acknowledged that at the time care was provided the resident was saying no, that they decided to “just get it done,” and that a skin tear on his hand was discovered and treated afterward. The administrator later stated that staff believed the resident was not physically resisting but was saying no, and that they concluded he ultimately cooperated.
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