A resident with CHF, COPD, and intact cognition was given Furosemide twice before leaving for an outside counseling appointment, despite a care plan noting urinary incontinence and mechanical-lift transfer needs. The resident reported that staff usually held the diuretic until return from the appointment, but on this occasion the medication was given before departure, leading to three incontinent episodes while out and emotional distress on return. The DON acknowledged the dose should have been held because the appointment was brief and the resident could not be toileted at the counseling office.
Failure to maintain resident dignity during mealtime assistance: A DON and CNAs were observed standing over two dependent residents while feeding them in the dining room, and the staff did not converse with the residents during the meals. One resident had severe dementia and was dependent for eating, and the other had vascular dementia, CVA-related deficits, swallowing difficulty, and required assistance with all meals. The facility policy stated staff should focus on the resident, talk to the resident individually, and be seated if possible while feeding.
A resident with Parkinson's Disease and dementia, and severe cognitive impairment per BIMS, was observed during lunch being fed by a CNA who stood the entire time instead of sitting beside the resident. The DON stated staff are expected to sit next to residents when assisting with meals, but could not explain why the CNA stood while feeding the resident.
A facility failed to provide dignified meal assistance when 2 staff were observed helping 6 residents at once, leaving some residents waiting while food sat in front of them. Staff reported they could not sit with residents or converse with them because they were assisting too many people, and leadership stated staff should be seated with residents during feeding. In separate observations, CNAs stood while feeding residents for the entire meal and used clothing protectors as napkins, despite care plans calling for feeding assistance and dignified support.
Failure to honor a resident's refusal of a Scopolamine patch. An MA attempted to apply the patch without first explaining the procedure, and the resident showed non-verbal signs of refusal by pulling away, shaking the head, and grimacing. Even after the resident indicated no, the MA held the resident's face and placed the patch anyway. RN stated these were signs of refusal, and the DON acknowledged the MA did not follow standards of care.
A resident with CVA, dysphagia, aphasia, and moderate cognitive impairment was denied an advanced diet unless she ate in the dining room for supervision, despite preferring to eat in her room. She frequently refused pureed meals, had significant weight loss and malnutrition, and staff confirmed she could have a minced diet with supervision. The ST also stated the resident and family were not educated on the risks and benefits of regular-texture foods, and no consent was obtained for eating regular foods in her room without supervision.
Two residents were not treated with dignity and respect in common areas. One resident with MS was observed in a gown with the back and side exposed while being assisted to activities, and staff said the resident preferred a gown and needed help staying covered. Another resident with debility and dementia was observed sitting in the common area wearing only a t-shirt and incontinence brief with the bottom half exposed while staff walked by; a CNA later covered the resident with a blanket, and the NHA acknowledged residents should be dressed appropriately for dignity.
A resident with intact cognition and diagnoses including CAD, TIA/cerebral infarction, and major depressive disorder wanted to smoke, but staff removed the resident’s vape and told the resident smoking was not allowed. The resident said no one discussed smoking or offered cessation help after the vape was taken. The DON confirmed no smoking assessment was completed to determine whether the resident could smoke independently or with assistance, and no discussion about smoking or cessation was offered after the vape was removed.
A resident with intact cognition and documented preferences for choosing clothes was repeatedly observed wearing a hospital gown while eating and moving about the facility, despite stating a preference for regular clothing and having only one change of clothes. Another resident with multiple chronic conditions was repeatedly observed in the same soiled shirt and pants with dried food and liquid, and stated there were no other clothes available. Staff interviews confirmed the residents lacked appropriate clothing options during the survey observations.
A cognitively intact resident with multiple chronic conditions, including COPD and chronic myeloid leukemia, was care planned to be encouraged to use the toilet for bowel evacuation, but staff followed Kardex instructions to use a bedpan and at times only placed incontinence pads under her instead. The resident reported to police that she had been left sitting in her bowel movement for several hours and that staff used chucks instead of a bedpan, causing discomfort and embarrassment. In interviews, she stated she preferred to be transferred with a lift to the toilet and had recently tolerated a sit-to-stand lift well. An LPN acknowledged miscommunication between shifts that led to the resident not receiving needed care and stated that residents required more attention than staff could provide, demonstrating a failure to provide dignified, care-planned toileting consistent with the resident’s preferences.
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