Privacy Deficiency in Resident Care
Penalty
Summary
The facility failed to ensure privacy for four residents, resulting in feelings of shame and embarrassment. Resident 108, who has moderate memory impairment, was observed disrobing at her bedside with curtains that did not fully cover her personal space, leaving her visible from the hallway. Resident 53, also with moderate memory impairment, had a missing slat in the vertical blinds, allowing visibility into her room from the courtyard. Despite having reported the issue to staff, the slat had not been replaced. Resident 1, with moderate memory impairment, expressed discomfort due to a missing slat in the vertical blinds, fearing that people could see into her room at night. Resident 10, with severe memory impairment, was exposed during a change as the privacy curtain was not fully utilized, leaving her perineal area visible from the doorway. CNA 1 acknowledged the exposure but did not adjust the curtain, citing concerns about disturbing a roommate. Resident 10 reported feeling ashamed by the lack of privacy during such personal care. Interviews with the facility's Administrator and Director of Nurses confirmed that the expectation was for privacy to be maintained during resident care. However, a review of the Maintenance Log showed no entries for repairs to the curtains or blinds in the affected residents' rooms. The facility's policy emphasized the importance of promoting and protecting resident privacy, which was not upheld in these instances.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The curtains that were not reaching around, and the missing and/or broken blinds were immediately addressed and repaired by the maintenance director for residents 108, 51, 01, and 10 to preserve their dignity and uphold their rights. To date, the curtains for the affected residents fully close, providing adequate privacy; and the blinds are complete and in working condition. The residents were reassured and expressed satisfaction with the outcomes. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents can potentially be affected by the alleged deficient practice as failure of the facility to ensure that residents were treated with dignity and their privacy was protected when curtains did not reach around the resident's personal space and vertical blinds were broken/missing. Upon identification of alleged deficient practice, the Maintenance Director made rounds to the other rooms and no similar findings identified. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: It is the policy of the facility to ensure that residents are afforded privacy and dignity through adequate curtain coverage and complete and properly functioning blinds. On 3/11/2025, the Director of Staff Development (DSD) conducted an in-service to Maintenance Director, Housekeeping, Certified Nursing Assistants (CNA), Licensed Nurses (LN), and all other staff regarding policy and procedure on resident's rights with emphasis on dignity, privacy, and call light response through curtains reaching around them, and functional blinds. Licensed Nurses (LNs), Certified Nursing Assistants (CNAs), Housekeeping Staff, interdisciplinary team (IDT) managers, and all other staff will continue to note in the maintenance log any issues regarding curtains and/or blinds in resident's rooms. The Maintenance Director/Designee will review the log on a daily basis and address any concerns. During their rounds, IDT managers will assess the functionality of curtains and blinds and document findings in their room round sheets accordingly, and notify maintenance director/designee immediately. How does the facility plan to monitor its performance to make sure that solutions are sustained? Findings from facility rounds/maintenance log will be discussed during Daily Stand-up meetings. Administrator/designee will monitor for compliance. Interventions to be reviewed in the next QAPI meeting. The administrator will bring 2567 and POC to the QAPI meeting to discuss and ensure understanding for the next 3 months or until substantial compliance is achieved. Completion Date: 03/11/2025