Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of two residents during the recertification survey. Resident #32, who had intact cognition and an indwelling catheter, was observed multiple times with their urinary drainage bag uncovered and visible from the hallway. This was contrary to the facility's policy, which mandates the use of dignity bags to cover catheter drainage bags at all times. Interviews with staff revealed a misunderstanding about the policy, with a Certified Nursing Assistant believing the dignity bag was only necessary when the resident was out of bed. The Director of Nursing confirmed that dignity bags should always be used, regardless of the resident's location. Resident #40, who had moderately impaired cognition and required total assistance for eating, was observed being fed by an LPN who remained standing while spoon-feeding the resident. This action required the resident to raise their head to receive food, which was inappropriate and against the facility's practice of ensuring dignity and proper feeding techniques. The LPN acknowledged the inappropriateness of their actions, and the Director of Nursing reiterated that staff should be seated while feeding residents to maintain dignity and ensure safety.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 Element #1 The CNA whom had resident # 32 was disciplined for not providing the dignity cover for the foley. The LPN whom fed resident # 40 resigned. It is the policy of the facility to ensure proper dignity to all residents. Element #2 All residents in the facility, with Foleys, were reviewed to ensure proper dignity bags are provided. All nursing staff will be in-serviced on proper use of dignity bags. All nursing staff will be in-serviced about not standing while feeding a resident. Element #3 The Director of Nursing reviewed the policy and procedure for dignity and updated accordingly to include and specify feeding a resident while standing and dignity bags for foleys. Element #4 Using a standardized audit tool, the Director of Nursing/designee will conduct an audit of: a) All residents, with foleys, will have a random check weekly for 4 weeks then monthly for 3 months to ensure dignity bags are in place. All findings will be reported to the quality assurance committee for the next two QAPI meetings. b) During meals, in the main dining room, there will be a random check weekly for 4 weeks then monthly for 3 months to ensure proper dignity while feeding a resident. All findings will be reported to the quality assurance committee for the next two QAPI meetings. Element #5 The Director of Nursing Date of completion 5/1/2025