Failure to Maintain Resident Dignity During Ambulation
Penalty
Summary
The facility failed to maintain the dignity of Resident 97, who was admitted with a diagnosis of chronic ureteropelvic junction obstruction and had a nephrostomy tube. The resident was cognitively intact and required assistance for daily care needs. On December 9, 2024, during an observation, it was noted that while being assisted with ambulation to the therapy department by a therapy assistant, the resident's gown was held in a manner that exposed the back of his brief, legs, and drainage bag, compromising his dignity. Interviews with the Director of Therapy and the Director of Nursing confirmed that the resident should have been wearing clothing that maintained his dignity during ambulation.
Plan Of Correction
1. Unable to retroactively correct form of clothing for resident 97. 2. Baseline audit completed of residents to ensure dignity. 3. Non-clinical rounds to be completed by facility managers to make sure resident rights are met including dignity during ambulation. The Administrator/Designee will educate facility staff including therapy and agency on resident rights which includes dignity. 4. The Administrator or designee will complete dignity audits of 5 residents weekly for four weeks then monthly times one month. Identified issues will be addressed when found. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.