Failure to Ensure Dignity, Respect, and Adequate Incontinence Care for Multiple Residents
Summary
The deficiency involves multiple failures to honor residents’ rights to dignity, respect, self-determination, and appropriate care, particularly related to staff interactions, incontinence care, and response to call lights. Resident #4, who is cognitively intact with significant mobility limitations, pain, osteoporosis with pathological fracture, and urinary incontinence, reported that a nurse aide (NA B) repeatedly failed to return after agreeing to assist and ignored requests for help, including assistance to prepare for scheduled smoking breaks. Resident #4 described NA B yelling down the hall, accusing the resident of “putting things in my mouth,” and characterized NA B as rude, lacking compassion, and potentially aggressive. The resident also reported that another CNA told the resident to be quiet when calling for help, that staff often told the resident to wait and then did not return, and that the only way to get staff attention was to yell. Progress notes documented that the resident frequently yelled and screamed for help if not assisted right away, and Resident Council minutes noted call lights not being responded to on time. Resident #4 further reported significant issues with incontinence care and supplies. The resident stated that staff did not check on or change incontinence briefs for extended periods, leading to a brief that, when weighed with a CNA, was found to weigh about one to 1.3 pounds, and that this was reported to LPNs and the DON, who allegedly responded dismissively. The resident reported being left without appropriate briefs, being out of briefs the prior day, and that staff used briefs that were too big or too small because the facility frequently ran out of the correct size. CNAs corroborated that the facility had ongoing supply shortages of briefs and wipes, that several residents did not have enough briefs, that staff sometimes had to use bariatric or incorrect sizes, and that wipes were unavailable at times, requiring use of wet paper towels and washcloths. One LPN stated that residents may be left soiled at night because some mornings residents were found soaking wet. The DON acknowledged a shortage of briefs, ordering constraints tied to budget, and that staff were instructed to place only a few briefs in rooms at a time. Resident #5, cognitively intact with osteoporosis, anxiety, depression, COPD, and frequent incontinence, reported that NA B was rude and talked over the resident about the aide’s personal dating life while the resident was being changed, making the resident uncomfortable and leading the resident to request that NA B no longer provide care. LPN J confirmed that Resident #5 complained about NA B’s rudeness and that NA B and another CNA had an inappropriate conversation about dating while providing incontinence care. LPN J also reported that residents had complained about NA B being rude, and had personally heard NA B say impatiently in front of the nurse’s desk, “My God, [resident’s name], what do you want now?” Other staff, including a CMT and CNA, stated that staff were expected not to yell at residents, not to talk about personal lives, and not to talk over residents during personal care, indicating that NA B’s conduct was inconsistent with these expectations. Resident #6, cognitively intact with paraplegia, depression, and chronic pain, reported that when the resident asked NA B to remake an improperly made bed, NA B became irritated, walked off to use a phone, did not return to complete the task, and subsequently ignored the resident when passing by. Additionally, CNA D reported witnessing NA B inappropriately restrain another resident (Resident #2) by holding the resident’s arms and hands behind the back “like he/she was being arrested” while walking the resident from the business office manager’s office to the special care unit, during which the resident was upset, crying, and verbally refusing. CNA D stated that other staff witnessed this incident and that it was reported to the DON. Across these events, the administrator and DON both articulated expectations that staff should not tell residents to be quiet, should not yell at or talk over residents, should not ignore residents, and should respect residents’ wishes, but the described staff behaviors and supply failures did not align with those expectations and contributed to the identified deficiency in resident rights and dignity. Additional documentation supports a pattern of delayed response to residents’ needs and disregard for resident comfort and preferences. Progress notes for Resident #4 described frequent yelling for help when assistance was not provided promptly, and staff interviews indicated that some staff told the resident that they were not the only resident needing care and that the resident should not yell because it disturbed others. The DON stated that if a call light was not answered as quickly as the resident wanted, the resident should not be yelling, and that staff encouraged call light use, while Resident Council minutes documented concerns about call lights not being answered timely. For Resident #5, progress notes described the resident as demanding and yelling out “help” after a few minutes when slightly incontinent, and preferring to stay in the room with the door closed, but there was no indication that staff adjusted their approach to address the resident’s expressed discomfort with staff conversations during care. Collectively, the report details multiple instances where staff actions and inactions, including rude and dismissive communication, failure to respond promptly to requests and call lights, inadequate incontinence care, and inappropriate physical handling, failed to uphold residents’ rights to dignity, respect, and appropriate care as outlined in facility policy and resident care plans.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Staff failed to honor a resident’s expressed preference to use a mounted doorbell instead of knocking before entering the room. The resident had PTSD and a history of trauma, and knocking was a known trigger. During observation, a CNA knocked, rang the doorbell, and opened the door while the resident was being interviewed, despite a posted sign requesting staff ring the bell and not knock. Interviews confirmed staff knew the resident’s preference and trigger.
Failure to maintain resident dignity and privacy during care: multiple residents reported CNAs used personal cell phones while assisting with showers, peri-care, and other care, including texting and talking in resident areas and during meals. A resident with stroke-related paralysis and severely impaired cognition was observed receiving wound care with the door open and the privacy curtain not pulled, allowing others to see into the room while the LPN provided care.
A resident who was dependent on staff for toileting and transfers, and who was frequently incontinent, was left in bed in only a sweatshirt and brief while crying after staff told her to stay in bed and pee her pants so they could clean her up later. The resident said this happened often and that her call light was frequently turned off. Staff interviews confirmed she should not have been told to remain incontinent, and the DON stated residents should never be told to be incontinent because it is a dignity issue.
A resident with a foley catheter was observed with the catheter bag hanging uncovered on the side of the bed while the room door was open. The resident had diagnoses including stroke-related hemiplegia/hemiparesis and UTI, and the care plan noted a foley catheter related to neurogenic bladder. CNA staff stated the bag should have been covered, and the DON acknowledged it was a privacy issue.
Failure to Maintain Female Residents' Dignity With Unwanted Chin Hair: Three female residents were observed with visible chin hair after showers, despite needing staff assistance with bathing and grooming. Two residents had severe cognitive impairment and one had moderate cognitive impairment; one resident said the hair bothered her and another said she was waiting for the beauty shop to shave it off. Family members stated the residents would not choose to have beards and that the unwanted chin hair caused embarrassment and affected dignity.
A resident with impaired cognition, incontinence, and a catheter for neurogenic bladder had his catheter drainage bag visible in the commons area and later from the hallway, with clear yellow urine showing. Staff, including therapy, the IP, and an RN, did not arrange privacy, and the bag was also hung facing out toward the room entrance. The DON stated staff were expected to keep the blue side of the bag facing the public to cover it and maintain dignity.
Staff Failed to Honor Resident’s Doorbell Preference
Penalty
Summary
The facility failed to ensure staff treated Resident #39 with dignity and respect by honoring the resident’s expressed preference for how staff announced themselves before entering the room. Resident #39 was admitted with diagnoses that included PTSD and frontal lobe and executive function deficit, and stated during interview that knocking on the door was a known trigger related to a history of trauma. The resident preferred that staff use the mounted doorbell instead of knocking when the door was shut for privacy. During observation, CNA #2 approached the resident’s room, knocked on the door, rang the mounted doorbell, and then opened the door while surveyors were interviewing the resident. The resident responded, “Not now, I’m busy,” and the CNA closed the door. A sign posted outside the room stated, “Pls. Ring the Bell, Don’t Knock! STOP,” and a doorbell was mounted next to the sign. Interviews with the ADON and CNA #9 confirmed staff were aware of the resident’s preference and that knocking was a known trigger, yet the observed practice did not follow the resident’s stated wishes.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and privacy by allowing staff to use personal cell phones while providing care and by failing to maintain privacy during wound care for one resident. Twelve confidential residents stated that CNAs used personal cell phones while assisting with showers, providing care in resident rooms, and performing peri-care, and that staff also texted and talked on phones while walking in hallways, at nurses’ stations, and in the dining area during meals. The residents stated this occurred on every shift and made them feel embarrassed, concerned about the quality of care, and that their privacy was violated. During interviews, the DON and ADM stated staff should not use cell phones or earbuds while providing care and should keep phones in breakroom lockers. They stated residents should receive undivided attention and that staff were trained on resident rights, dignity, privacy, and cell phone use during orientation, ongoing education, and in-services. They also stated staff were monitored through rounds, and both acknowledged that cell phone use in resident care areas could violate privacy and reduce attention to care. Resident #7 was a male resident with a history of cerebral infarction, left-sided hemiplegia and hemiparesis, and urinary tract infection, and his MDS indicated severely impaired cognitive skills for daily decision making. During observed wound care, LVN D did not close the door or pull the privacy curtain around the resident, and two female residents were seen passing by and looking into the room while care was being provided. LVN D stated she had been trained to close the door and pull the curtain but did not do so because she was waiting for the CNA, and the DON and ADM stated they expected the door to be closed and the curtain pulled for privacy during resident care.
Failure to Preserve Resident Dignity During Toileting Assistance
Penalty
Summary
The facility failed to ensure dignified care for one resident who was dependent on staff for toileting and transfers, frequently incontinent of bowel and bladder, and had diagnoses that included dementia, diabetes, non-traumatic spinal cord dysfunction, depression, heart failure, and asthma. Her care plan directed staff to assist her with toileting, provide incontinence care, and offer toileting every 3 hours so she could remain free of skin breakdown and have her dignity respected. She was also documented as being able to verbally ask for toileting assistance and requiring extensive assistance with transfers and toileting needs. During an observation, the resident was found lying in bed wearing only a sweatshirt and an incontinent brief, with no pants and not fully covered by bedding. She was crying and stated staff told her she had to stay in bed and could not get up, and that they told her to pee her pants and they would clean her up in bed. She stated this happened all the time and that nursing assistants shut off her call light just about every day. While she was crying, a nursing assistant entered, said she was wet and needed to be cleaned up, told her not to cry, and then provided incontinent care. During interviews, staff acknowledged the resident should not be told to go in her pants or be encouraged to remain incontinent. One NA stated the resident was encouraged to stay in bed because staff were short and the NA had other residents to care for, and that the resident had asked to get up but was waiting because she required assistance of 2. Other staff stated the resident should never be told to just go in her pants, that residents should not be told to be incontinent, and that such statements were a dignity issue. The DON stated staff were expected to provide care when requested and never tell a resident to be incontinent because it was a dignity issue.
Uncovered Foley Catheter Bag Observed With Door Open
Penalty
Summary
The facility failed to ensure a resident was treated with dignity when Resident #3’s foley catheter bag was observed hanging on the side of the bed without a cover while the room door was open. Resident #3 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side and a UTI, and his care plan documented that he had a foley catheter related to neurogenic bladder. The facility’s Promoting/Maintaining Resident Dignity policy stated that residents are to be protected and promoted in their rights and treated with respect and dignity. During interview, CNA #1 stated the catheter bag should have been covered since the door was open, and the DON stated she had never thought the catheter should have been covered in the room with the door open and acknowledged it was a privacy issue.
Failure to Maintain Female Residents' Dignity With Unwanted Chin Hair
Penalty
Summary
The facility failed to treat three residents with dignity and respect when each had visible chin hair that was not consistently removed after bathing. Resident #1, a female resident with moderately impaired cognition, was dependent on staff for toileting and required assistance with bathing. Her record showed she was showered on 06/02/26, but on 06/03/26 and again on 06/04/26 she was observed with several white, approximately one-inch-long hairs on her chin. During interview, she stated the hairs bothered her and said she was waiting for the beauty shop ladies to come because they usually shaved her chin hair off for her. She also stated CNAs never shaved her chin. Resident #37, a female resident with severely impaired cognition, was dependent or required partial/moderate assistance across all ADLs except eating and required one staff member to assist with bathing. Her record showed she received a shower on 06/02/26. On 06/03/26, she was observed multiple times lying in bed with several dark and light grey hairs sprinkled across her chin, approximately half an inch long. During interview, her family member stated she would not choose to have a beard and that when at home she used a trimmer to remove unwanted chin hair. The family member also stated CNAs shaved her chin when they showered her. Resident #44, a female resident with severely impaired cognition, Parkinson's disease, lack of coordination, and muscle weakness, was dependent across all ADLs except eating and required two staff members for bathing. Her record showed she was showered on 06/02/26. On 06/03/26 and again on 06/04/26, she was observed with long, white, curling hairs on both sides of her chin. During interview, she stated it bothered her to have chin hair and that she did not like it. She said she could shave her chin if she had a razor and stated CNAs had shaved her chin in the past, but she did not know why they had not done so lately. Her family member stated the chin hair bothered her, that he had never seen her with chin hair before she came to the facility, and that she would become emotional and embarrassed if it was mentioned.
Visible Catheter Drainage Bag Not Kept Private
Penalty
Summary
The facility failed to ensure dignity was maintained for one resident who had moderately impaired cognition, was dependent on staff for dressing, bed mobility, and toileting, was always incontinent of bowel and bladder, and had intermittent catheterization for neurogenic bladder. The resident’s care plan identified a catheter and included an intervention to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. During an observation, the resident’s urinary catheter drainage bag was visible while he was seated in his wheelchair in the commons area, with clear yellow urine showing and the bag hung under the wheelchair. After the resident was brought to his room, staff emptied the catheter drainage bag and hung it on the side of the bed facing out to the room entrance. On a later observation, the catheter drainage bag was uncovered in the commons area, with the clear side facing toward the hallway and elevator space so that clear yellow urine was visible from the hallway. Therapy staff, the infection preventionist, and the resident’s RN were present in the area and did not arrange privacy for the catheter drainage bag. Staff later stated the bag should be covered for privacy, and the DON stated staff were expected to keep the blue side facing the public to cover the bag and maintain dignity. The facility’s dignity policy stated catheter drainage bags and colostomy pouches should be covered with commercial covers or tucked out of plain sight.
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