A resident with hemiplegia, hemiparesis, and vascular dementia was transferred in a mechanical lift from her room into a hallway to a reclining shower bed while only partially covered with a bath sheet, leaving her hips and buttocks exposed to others in the area. The resident said she did not like being left exposed, and staff stated the bed was usually placed outside her room because of space limits, though the DON expected her dignity to be preserved during the transfer.
Dignified Dining Practices Not Maintained: A nurse was observed standing while assisting a resident with eating, despite the facility’s expectation to sit when providing feeding assistance. In a separate dining observation, one resident at a table was served more than 10 minutes after the other residents at the same table had already received their meals and begun eating, while the DON and Dietary Manager stated meals should be delivered to the entire table at the same time to maintain dignity and respect.
A resident with ESRD and dialysis refusal was subjected to a guardianship filing by facility staff without notifying her or her family and without a formal competency assessment. The resident was her own RP, the MDS coded her as cognitively intact, and the Medical Director noted she had not been declared incompetent. The SW filed the petition after being directed by the Administrator, while the resident stated she did not want the facility controlling her decisions and her daughter said she would have wanted to serve as guardian if needed.
Failure to Maintain Resident Dignity and Respect: Two cognitively intact residents reported disrespectful interactions with NAs. One resident said an NA confronted her about complaints made to management and accused her of false accusations, leaving her fearful and treated unfairly. Another resident said a different NA spoke in a rough, belittling manner and never said anything kind, which left him frustrated.
Staff failed to respect resident privacy and dignity when a CNA entered two residents’ rooms without knocking and a nurse made a disrespectful comment in the hall about a resident’s HIV status. The cognitively intact residents reported feeling angry, embarrassed, hurt, and without privacy after staff entered rooms and even a bathroom without permission, and after overhearing the nurse’s negative remarks about a meal complaint.
A cognitively intact resident with heart failure, an above-knee amputation, and arthritis was involved in a verbal altercation with an RN over early pain medication. Witness statements and staff interviews described the RN using profanity, making derogatory comments about the resident’s disability, yelling, and moving into the resident’s personal space while the resident also shouted offensive remarks. The DON and Administrator stated the nurse should have disengaged from the confrontation.
Failure to Honor Resident’s Dignity and Care Plan Preference: A resident with profound ID, blindness, severe cognitive impairment, and nonverbal status had a care plan noting she sometimes sat on the floor when agitated or wanting to be alone and that this preference would be honored. Video showed an NA first trying to lift her while seated, then, after she resisted, lifting her from behind and dragging her down the hall and backward into her room. A witness reported the resident was calmer on the floor and that the NA told her she could not stay there because she had other residents to care for.
Undignified Communication With Resident During Call Bell Interaction: A resident with hemiplegia/hemiparesis after CVA and moderate cognitive impairment was observed with her call bell left on the floor after staff assistance. When the resident began touching the call bell, an NA spoke sternly and told her not to hit it, despite standing nearby. The resident said the interaction upset her, and the DON stated the NA spoke inappropriately and the resident had the right to be spoken to in a dignified manner.
Resident Left in Soiled Brief After Request for Care: A cognitively intact resident who was fully dependent for ADLs and incontinent of bowel reported needing a brief change, but an aide delayed care to feed residents in the dining room and then waited for another aide to assist. The resident said she remained soiled for nearly 2.5 hours, felt gross, and missed going outside on the porch. The DON and PA stated there was no reason for the resident to sit in a soiled brief for an extended period after staff were made aware.
Dignified Dining Service: A resident who was cognitively intact and needed only set-up/clean-up assistance was seated with another resident when the dining attendant served the tablemate first and then served other residents before returning with the resident's tray. The resident watched others eat while waiting and said he was upset that he was the last one served; the attendant said an alternate meal had to be obtained from another dining room, and the DR supervisor, DON, and Administrator stated residents at the same table should be served at the same time.
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