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
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Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to Knock Before Entering Rooms and Exposed Urinary Bag: A CNA entered three residents' rooms without knocking, and each resident said staff should knock and that they preferred privacy. The residents had diagnoses including encephalopathy, heart failure, respiratory failure, malnutrition, and sepsis, with moderate cognitive impairment documented for three of them. In addition, a resident with a urinary catheter was observed with an exposed urine bag hanging from the bed without a privacy cover, and the urine could be seen from the hallway; interviews confirmed privacy covers were required and that exposed urine affected dignity.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's dignity was not maintained during a blood sugar check when an RN performed the finger stick in the day room with two other residents and a visitor present and loudly announced the result. The RN did not ask permission before checking the resident's blood sugar in the common area, and the resident was described as alert, oriented, and new to the facility.
Cell Phone Use During Resident Care: CNAs were observed and reported using personal cell phones while providing care, including showers, in resident rooms, at nurses’ stations, in hallways, and while supervising smoking times. Nine confidential residents said the behavior made them feel ignored, embarrassed, and that their privacy was violated. The DON and ADM stated residents should receive privacy and full attention during care, and the facility policy required staff to treat residents with kindness, respect, dignity, privacy, and confidentiality.
Staff failed to maintain resident dignity during wheelchair transport and assisted feeding. A resident with dementia and severe cognitive impairment was transported in a geriatric wheelchair while facing backward, slumped over, and moaning as a CNA pulled the chair from the front, preventing the resident from seeing where he was going. Two cognitively impaired, fully dependent residents were assisted with eating by CNAs who stood over them rather than sitting at eye level, despite chairs being available in the room and dining area. One CNA reported not knowing she was expected to sit while feeding, and another stated she remained standing to monitor other residents who were self-feeding while she was the only staff member present.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Knock Before Entering Rooms and Exposed Urinary Bag
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity when CNA B did not knock before entering the rooms of Resident #20, Resident #59, and Resident #64. Resident #20 was a female with diagnoses including metabolic encephalopathy, hypertensive chronic kidney disease, hyperlipidemia, hypertension, weakness, and unsteadiness on feet, and her BIMS score was 08. Resident #59 was a female with diagnoses including heart failure, respiratory failure, muscle weakness, GERD without esophagitis, hypertension, and sepsis, and her BIMS score was 10. Resident #64 was a male with diagnoses including protein-calorie malnutrition, sepsis, hypertension, kidney failure, and alcohol abuse, and his BIMS score was 09. Each resident stated staff did not knock on the door and that they wanted staff to knock before entering their rooms. Observations during breakfast tray pass showed CNA B entering Resident #59's room at 7:17 a.m., Resident #64's room at 7:25 a.m., and Resident #20's room at 7:28 a.m. without knocking first. During interviews, Resident #59 said staff were supposed to knock and that staff would just walk in, including when she was being changed. Resident #64 said staff walked into his room all the time and that he got irritated when they did not knock. Resident #20 said staff never knocked on the door and that she preferred they knock, especially if the door was closed. The facility also failed to ensure Resident #102's urinary catheter had a privacy cover. Resident #102 was a female with diagnoses including hearing loss, pain, hypertension, cognitive communication deficit, and a rib fracture with pain, and her BIMS score was 99, indicating unable to complete the interview. Observations showed a urinary bag hanging from the side and bottom of her bed with no privacy cover, and the urine was visible from the hallway. Interviews with CNA B, MA F, CNA A, Central Supply, and the DON indicated privacy bags were supposed to be used for urinary bags and that exposed urine affected dignity and self-worth. The resident's care plan did not reflect anything about the catheter, and the report states the Dignity Policy required each resident to be cared for in a manner that promotes and enhances well-being, satisfaction with life, and feelings of self-worth and self-esteem.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Maintain Resident Dignity During Blood Sugar Check
Penalty
Summary
The facility failed to maintain a resident's dignity during a blood sugar check for Resident 97. During an observation on 5/1/26 at 11:21 a.m., RN 1 prepared to check the resident's blood sugar while the resident was sitting in her wheelchair in the day room with two other residents and a visitor present. RN 1 told the resident she was going to check her blood sugar, stuck the resident's finger, checked the blood sugar, and announced the result loudly in the common area. RN 1 did not ask the resident for permission to perform the blood sugar check in the common area with others present. During an interview later that day, Unit Manager 1 stated the resident was alert and oriented and new to the facility, and that they were working on a care plan indicating the resident was okay with having her blood sugar checked in common areas.
Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and care in a manner that promotes quality of life and recognizes each resident’s individuality for 9 confidential residents. The deficiency was based on resident interviews and record review showing that CNAs were using personal cell phones while providing care, including assisting with showers, performing care in resident rooms, and supervising residents during supervised smoking times. Residents stated staff texted and talked on their phones while walking in hallways, at nurses’ stations, and while performing care in their rooms, and they reported that this occurred on every shift and often in the facility. The residents also stated they did not know the names of the CNAs involved. The 9 confidential residents stated the cell phone use made them feel ignored, not a priority, embarrassed, and concerned that a CNA could make a mistake because of distraction. They also stated their privacy was violated. During interviews, the DON and ADM stated residents should receive privacy and full attention during care, and both stated staff were trained on privacy, resident rights, dignity, and cell phone usage. The record review included the facility policy titled Resident Rights, dated February 2021, which stated employees shall treat all residents with kindness, respect, and dignity and that residents have the right to a dignified existence, to be treated with respect, kindness, and dignity, and to privacy and confidentiality.
Failure to Maintain Resident Dignity During Transport and Assisted Feeding
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity and respectful treatment during transport and meals. One resident with dementia, anxiety, severe cognitive impairment, and total dependence for ADLs was observed seated in a geriatric wheelchair, slumped over with his head hanging and eyes open, and moaning while a nurse aide pulled the chair down the hall from the front, causing the resident to face backward and be unable to see where he was going. The aide reported she pulled the chair because it was hard to push and acknowledged she had been educated on dignity and respect and should have pushed the resident in front of her, which would have allowed her to see his slumped posture and hear his moaning. The DON confirmed that the resident should have been pushed in front of the aide and that this was a dignity issue. The deficiency also includes failure to promote dignity during meals for two residents with severely impaired cognition who were dependent on staff for eating. One resident with a traumatic brain injury was observed in bed with the head of the bed elevated while an agency nurse aide stood over the bedside and assisted with eating without sitting at eye level, despite a chair being available in the room; the aide stated she had never heard of needing to sit to feed a resident and only sat after being questioned. The other cognitively impaired, fully dependent resident in a semi-reclined geriatric chair in the dining room was fed by the same nurse aide, who stood over the resident while feeding despite an empty chair being available; the aide later stated she believed she had no chair and also needed to stand to watch three other residents feeding themselves at another table while she was the only staff member present in the dining area. The DON stated she expected staff to sit when assisting residents during meals to promote dignity.
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