Resident Dignity and Dining Experience Deficiencies
Penalty
Summary
Brighton Rehabilitation and Wellness Center was found to be non-compliant with certain resident rights requirements as per 42 CFR Part 483, Subpart B, and the 28 Pa. Code. The facility failed to maintain the dignity of two residents. One resident, admitted in 2015, was observed self-propelling in a wheelchair wearing only a sweatshirt, socks, and a brief, without proper lower body clothing. A Licensed Practical Nurse acknowledged this issue, indicating a failure to ensure the resident was dressed appropriately, thus compromising the resident's dignity. Another resident, admitted in 2024, had a pressure ulcer on the right buttock, and during wound care, a nurse wrote on the dressing after it was applied, which was confirmed as a failure to maintain the resident's dignity. Additionally, the facility did not provide a dignified dining experience for residents during observed lunches. All residents in the dining rooms were served with plastic utensils instead of metal silverware, which was confirmed by the Dietary Manager. This practice was consistent over multiple days and was noted during tray line observations, indicating a systemic issue in providing a dignified dining experience for the residents.
Plan Of Correction
1. R149 was offered a blanket to cover his lap. Employee E3 was educated on maintaining dignity by dating dressings for residents prior to placing on the body. Residents whom received plastic cutlery on 2/10/25 through 2/12/2025 suffered no ill effects. 2. Walking rounds were done on 2/13/2025 by assistant director of nursing to ensure that residents who were out of bed were covered appropriately. No issues identified. 3. Director of nursing or designee will in service licensed nursing staff on dating wound dressings prior to placing on a resident. Director of nursing or designee will educate nursing staff on maintaining dignity by ensuring residents are covered appropriately. Administrator or designee will in-service dietary staff on providing metal cutlery unless otherwise ordered. 4. Director of nursing or designee will observe 5 dressing changes weekly for 2 weeks, then 3 dressing changes weekly for 2 weeks, then 3 dressing changes monthly for 2 months to ensure dressings are dated prior to being placed on resident. Director of nursing/designee will audit 6 units weekly for 2 weeks, then 3 units weekly for 2 weeks, then 3 units monthly for 2 months to ensure residents are covered appropriately. Audit findings will be shared with QAPI committee. Administrator or designee will audit meal trays weekly for 4 weeks to ensure metal cutlery is being provided.