Failure to Maintain Dignity During Resident Feeding
Summary
The facility failed to ensure respect and dignity for a resident by not maintaining eye contact during feeding. The incident involved a resident with dementia and hypertension, who was admitted to the facility initially in 2021 and readmitted in 2024. The resident required supervision or assistance with eating and other personal care activities due to severely impaired memory and cognition. During an observation, the resident was seen struggling to eat independently, and a CNA assisted by feeding the resident while standing, without sitting at eye level. The CNA acknowledged the importance of treating the resident with respect and dignity by sitting at eye level during feeding. The Director of Nursing confirmed that staff should sit at eye level to ensure dignity and respect. The facility's policy on assisting residents to eat also emphasized the need for staff to sit at eye level when feeding residents. This deficiency was identified through observation, interviews, and a review of the facility's policies.
Penalty
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A resident with an indwelling Foley catheter for obstructive uropathy, who was cognitively intact, had a care plan and physician order in place that included maintaining a catheter privacy bag. Surveyors observed the urine collection bag hanging on the hallway side of the bed without a privacy cover, making it visible from the corridor. In interview, the resident stated this was not dignified, and an LPN/unit manager confirmed that catheter bags should be covered so contents cannot be seen, acknowledging that the bag should have been covered to protect the resident’s dignity.
A resident with severe cognitive impairment and total incontinence was not offered incontinence care for over seven hours while being moved between rooms. Staff interviews confirmed that incontinent residents should be checked at least every two hours, and management acknowledged that extended lack of care can cause emotional distress and loss of dignity.
A resident with severe cognitive impairment was unable to identify a nurse who was not wearing a required name badge during care. The nurse, unfamiliar with the unit and residents, admitted to not having the badge visible, and staff confirmed that identification badges are a required part of the uniform. This failure to ensure staff identification did not promote dignity or respect for the resident, as required by facility policy.
A resident with severe cognitive impairment and swallowing difficulties was observed being fed by a CNA who stood next to the bed, rather than sitting, during feeding assistance. The resident was fully dependent on staff for eating, and the CNA acknowledged that standing while feeding was not dignified. This action did not align with the facility's policy on respecting resident dignity.
A resident was not offered a room change or diversional activities after his roommate died, despite being cognitively intact and facility staff stating this was standard practice. Documentation and interviews confirmed the omission, and the resident reported not being given the option to move rooms.
Facility staff did not ensure privacy for a resident with an indwelling catheter, as the catheter collection bag was repeatedly left uncovered and visible to anyone entering the room. The resident, who was alert with some forgetfulness and had a diagnosis of urinary retention, reported being bothered by the lack of privacy. This action was inconsistent with the facility's policy to treat residents with dignity and respect.
Failure to Maintain Privacy for Catheter Collection Bag
Penalty
Summary
Facility staff failed to promote a resident’s dignity by not providing privacy for an indwelling catheter collection bag. The resident, who was cognitively intact with a BIMS score of 15/15 and had diagnoses including obstructive and reflux uropathy/neurogenic bladder, had a physician’s order for a 16 French Foley catheter and a comprehensive care plan that specifically directed staff to maintain a catheter privacy bag. During an observation from the hallway, the resident’s catheter collection bag, containing urine, was seen hanging on the hallway side of the bed without any privacy cover, making it fully visible from the corridor. When interviewed, the resident reported not being aware that the catheter bag was uncovered and stated that she did not like it and felt it was not dignified. The unit manager LPN confirmed in interview that catheter collection bags should be placed in a privacy bag or otherwise covered so the contents cannot be seen, and acknowledged that the bag should have been covered to protect the resident’s dignity. Administrative staff, including the administrator, DON, regional director of clinical services, and ADON, were informed of these findings, and no additional information was provided before survey exit.
Failure to Provide Dignified Incontinence Care
Penalty
Summary
Facility staff failed to provide care in a dignified manner for one resident who was observed from 10:07 a.m. to 5:30 p.m. without being offered incontinence care. During this period, the resident, who was severely cognitively impaired and always incontinent of both bladder and bowel, was moved between various rooms but was not taken back to her room for incontinence care. Continuous observation confirmed that no staff member provided or offered incontinence care throughout the entire period. Interviews with CNAs and an LPN confirmed that incontinent residents should be checked at least every two hours, with some requiring more frequent checks, especially those unable to communicate their needs. Staff acknowledged that failing to provide timely incontinence care can lead to skin breakdown and is not consistent with treating residents with dignity. Facility management agreed that lack of incontinence care for an extended period could result in emotional distress and a diminished quality of life for the resident.
Failure to Ensure Staff Identification Compromises Resident Dignity
Penalty
Summary
The facility failed to promote and enhance a resident's right to a dignified existence and respect. A resident with severe cognitive impairment, as indicated by a BIMS score of 6 out of 15 and diagnoses including dementia, osteoarthritis, and metabolic encephalopathy, was observed during care interactions where staff did not follow established protocols for resident dignity. Specifically, a registered nurse providing care was not wearing a name badge, which is required as part of the staff uniform and is necessary for residents and families to identify staff members. The nurse admitted to not usually working on the unit, being unfamiliar with the residents, and not having the name badge visible because it had fallen off in the break room. When questioned, the resident was unable to identify the nurse by name and confirmed the absence of a name badge. Further interviews with other staff, including the unit manager and administrative staff, confirmed that wearing identification badges is a facility requirement and part of the uniform. The facility's Resident Rights policy states that each resident should be cared for in a manner that promotes well-being, satisfaction, self-worth, and self-esteem. The failure of the nurse to wear a name badge and ensure proper identification was recognized by staff as not demonstrating dignity and respect for the resident, directly contravening facility policy and resident rights.
Failure to Promote Resident Dignity During Feeding Assistance
Penalty
Summary
Facility staff failed to promote a resident's dignity during feeding assistance. A resident with severe cognitive impairment, vascular dementia, a history of CVA, and swallowing difficulties was observed being fed by a certified nursing assistant (CNA) who stood next to the bed while providing assistance. The resident was dependent on staff for eating, as documented in the care plan, and required support due to significant self-care deficits. The CNA confirmed during an interview that she stood while feeding the resident and acknowledged that this was not a dignified approach. The facility's policy on resident rights includes the right to be treated with respect and dignity, and to receive services with reasonable accommodation of resident needs and preferences. Despite this, the staff member did not follow practices that would uphold the resident's dignity during feeding. The deficiency was identified through observation, staff interview, and review of the clinical record, and facility leadership was made aware of the findings.
Failure to Offer Room Change or Diversional Activities After Roommate's Death
Penalty
Summary
A cognitively intact resident was not offered the opportunity to move to another room or participate in diversional activities after his roommate passed away. The resident's admission and assessment records indicated he was able to ambulate independently and had a perfect score on the Brief Interview for Mental Status (BIMS), confirming his awareness of the situation. Review of progress notes and interviews with staff confirmed that the facility did not document or offer the resident a room change or alternative activities following the death of his roommate, despite facility policy and staff statements indicating this should have occurred. Multiple staff interviews, including those with the Central Supply Manager, Administrator, LPN, and MDS Coordinator, revealed that it was standard practice to offer a room change or diversional activities to a surviving roommate after a death. However, the resident himself confirmed he was not offered another room. The Administrator also stated there was no specific policy for dignity in such situations. This lack of action and documentation failed to honor the resident's right to a dignified existence and self-determination during a potentially traumatic event.
Failure to Provide Privacy for Catheter Collection Bag
Penalty
Summary
Facility staff failed to promote the dignity of a resident with urinary retention who had an indwelling catheter. On two separate occasions, surveyors observed the resident's catheter collection bag hanging uncovered on the lower portion of the bed, with the contents clearly visible. The resident was alert with some forgetfulness, as documented in the facility's clinical admission assessment. The physician's order specified the use of an indwelling catheter with straight drainage due to urinary retention. During an interview, the resident expressed discomfort and stated that it bothered him that anyone entering the room could see the urine in the collection bag. The facility's policy on resident rights requires that each resident be treated with respect and dignity, and that care be provided in a manner that promotes or enhances quality of life. Despite this policy, the lack of privacy for the catheter collection bag was not addressed prior to the survey exit.
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