Resident Dignity Compromised by Visible Name Labels on Clothing
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, which compromised the maintenance or enhancement of their quality of life. This deficiency was identified during a recertification survey, where it was observed that a resident, who had severely impaired decision-making and memory problems, was ambulating independently in the hallway wearing socks labeled with their name on the top of the foot. This labeling was visible to other residents, staff, and visitors, which is contrary to the facility's policy on dignity, respect, and privacy in treatment and care. Interviews conducted during the survey revealed a lack of awareness among staff regarding the visibility of name labels on residents' clothing. The LPN Unit Manager stated that the labels were intended to ensure clothing items were returned to the correct resident after laundry, and they were not aware that such labels should not be visible. Similarly, the Social Worker did not perceive the visibility of the name label as a problem. However, the Director of Nursing acknowledged that visible clothing labels were a dignity issue and took steps to address the situation by requesting the relabeling of the resident's socks.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 Resident #65’s socks were immediately removed. Resident #65 was monitored for 5 consecutive days for any emotional distress with no issues noted. The resident’s care plan was reviewed and is in concert with the resident’s current needs, and a medical record review was completed with no abnormal findings. LPN #14 and the Social Worker were reeducated by ADON/Designee on resident dignity and privacy, as well as policy and procedure for clothing labeling. All residents to have clothing labeled in a non-visible area. Both the LPN and Social Worker state their understanding. All residents who have clothing labeled had the potential to be affected by the deficient practice. A full audit of each unit’s resident clothing was conducted by unit managers/designee to identify other potential residents affected by deficient practices. Any instances where clothing labels were found to be visible were rectified immediately. The Staff Educator/designee will conduct educational sessions for all nursing and laundry staff on resident dignity and the use of clothing labels, and policy and procedure for labeling clothing for residents, to ensure all residents are treated in a dignified manner, keeping labels private. Weekly audits will be completed by unit manager/designee to assure residents' rights are observed and policy and procedure is adhered to, with no name labels being visible. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ADON will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported at the monthly QAPI meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25.