Failure to Maintain Resident Dignity in Care Practices
Penalty
Summary
The facility failed to ensure that care was provided in a manner that maintained resident dignity across three units. Resident R31, who is nonverbal and unable to eat by mouth due to being NPO, was observed sitting in the dining room during mealtimes while other residents were eating. This situation was confirmed by LPN Employee E8, who acknowledged that it failed to maintain the resident's dignity. Additionally, Resident R65 was observed being fed by a nurse aide who was standing, which was confirmed by NA Employee E2 as not providing a dignified dining experience. Furthermore, Resident R81, who has a Stage 4 pressure ulcer, was subjected to undignified care when RN Employee E7 wrote on the dressing after it was placed on the resident's sacrum. This action was confirmed by RN Employee E7 during an interview. The facility's policy on resident rights and dignity, as well as the resident handbook, emphasize the importance of treating residents with respect and dignity, which was not upheld in these instances.
Plan Of Correction
Residents #81, #31 and #65 had no negative outcomes. There were no other concerns expressed during the survey related to dignity regarding dressing changes, residents in the dining room that are NPO, or CNAs standing and feeding residents. To prevent this from recurring, the DON/designee educated nursing staff on the regulatory requirements of F550 and dignity, with emphasis on not writing on dressings after placed on residents, not placing residents that are NPO in the dining room during mealtime, or feeding residents while standing up. To monitor and maintain ongoing compliance, the DON/designee will audit 3 meal services and 3 dressing changes weekly for 4 weeks, then monthly for 2 months. Negative findings will be addressed, and ad hoc education will be completed as necessary. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.