Dignity Issue Due to Delayed Meal Delivery
Summary
The facility failed to ensure that residents were treated with respect and dignity during meal times, as observed during a recertification survey. On the [NAME] Unit, a secure dementia unit, residents were seated at tables waiting for their lunch trays, but due to delays in the delivery of meal transport racks from the kitchen, some residents received their meals while others at the same table did not. This resulted in a situation where some residents were eating while others were left waiting, which was identified as a dignity issue. The facility's policy on resident rights emphasizes the importance of dignity and respect, yet the meal delivery system did not align with these principles. Interviews with staff, including LPNs and CNAs, revealed that the late arrival of meal transport racks was a known issue, and the kitchen staff was aware of the problem. The General Manager for kitchen and dining operations acknowledged the need for better coordination between nursing, kitchen, and dietary staff to ensure that all residents at a table are served simultaneously. The Director of Nursing Services also emphasized that even though residents on the dementia unit may be confused, they should still be able to eat together rather than watching others eat, highlighting the importance of maintaining dignity during meal times.
Plan Of Correction
Plan of Correction: Approved January 6, 2025 I. The following actions were accomplished for the residents identified in the sample: No specific residents were identified in the Statement of Deficiencies. On 12/30/24, a seating chart was developed by the Nurse Manager for the Kipp unit and provided to the Dietary Department, so that truck order of trays is consistent with seating chart and all residents at the same table receive their meal at the same time. On 12/4/24 the Staff Educator/designee provided Inservice training to the Kipp unit Nursing staff on meal service, including serving all residents seated at the same table their meal tray at the same time. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by same practice. Effective 12/30/24, education was provided to Nursing and Dietary staff related to the facility policy and procedure for the development of seating chart for all units for mealtimes, and dietary developing a system to arrange food trucks in table order so that all meal trays for residents at the same table arrive on the units at the same time by Food Supervisor. This education included staff discussion regarding importance of resident respect, dignity and quality of life as it relates to mealtimes, including concerns for residents at the same table receiving trays at the same time. This education also included the need to review and update seating charts on a routine basis and Nursing’s responsibility for alerting the Dietary Department of any changes needed to the truck tray order. Nurse Managers and Dietitians will conduct meal observations on a random basis for all meals and shifts weekly to identify any concerns related to meals not being served in table order. Issues identified with the food carts not being loaded in table order for distribution will be addressed by the Food Service Director for all reported concerns. Issues related to a resident being seated at a table that is inconsistent with the seating chart will be addressed by the Unit Nurse Manager. The Manager will update the seating chart, if indicated, or provide staff education regarding their responsibility to adhere to the seating chart during all meals. If a resident must be moved to another table for meals, the Manager will promptly update the seating chart. III. The following system changes will be implemented to assure continuing compliance with regulations: The Director of Food Service reviewed and revised, as needed, the Food Service policies and procedures related to preparation of meal trucks, including providing trucks in order of residents seating to ensure that all residents receive their meal at the same time at each table. The Chief Nursing Officer reviewed and revised, as needed, policies and procedures related to resident dining and meal service related to resident rights and quality of life and directed the development of resident seating charts for each unit, which will be updated, as needed, and be provided to dietary when updated. Effective 12/10/24, the Director of Food Service/Designee and Chief Nursing Officer/Nurse Managers/designee will monitor meals to ensure all residents at same table are provided with meals at same time daily for 4 weeks, weekly for 2 months, then quarterly. Corrective action, including Nursing of Food Service staff re-education, will be implemented as necessary. The Staff Educator/Director of Food Service/designee will provide additional education to all Nursing and Dietary staff whenever issues related to residents receiving meals at same time when seated at the same table are identified. The Director of Food Service will review meal service findings with the Administrator monthly for three months then quarterly. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with Resident Rights related to meal service including residents at same table receiving meals at same time, accuracy of seating charts and accuracy of meal tray order on trucks to ensure meal service promotes resident dignity and respect and quality of life. The Director of Food Service/Designee will conduct monitoring of residents at same table receiving meals at same time monthly for three months then quarterly for the next nine months. The Director of Food Service/Designee will conduct competency evaluations of all Food Service workers to assure they are following established protocols and have a clear understanding of the protocols for proper truck order. On-site education will be provided, as necessary, to ensure staff compliance. Competency evaluations will be conducted of all new Food Service Workers upon completion of orientation and twice yearly thereafter. Chief Nursing Officer/designee will conduct meal service observations of nursing staff job performance during meal service to ensure resident respect and dignity and quality of life concerns are addressed when identified. Observation will include assessing the development and currency of seating charts, communication of updates to the Dietary Department, and residents being in their designated seating area for meals. The Food Service Supervisor/designee will report residents’ meal service audit findings to the QAPI Committee monthly for the next 3 months then quarterly for the next 3 quarters. At the end of the fourth quarter, a decision will be made by the QAPI Committee regarding the need to continue auditing and at what frequency. Additional corrective action will be implemented as deemed necessary by the Committee. The Chief Nursing Officer will report meal service observation audit findings to the QAPI Committee monthly for the next 3 months then quarterly for the next 3 quarters. At the end of the fourth quarter, a decision will be made by the QAPI Committee regarding the need to continue auditing and at what frequency. Additional corrective action will be implemented as deemed necessary by the Committee. Completion Date: 01/31/2025 Responsibility: Director of Food Service
Penalty
Resources
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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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