Failure to Maintain Resident Dignity Post-Meals
Penalty
Summary
The facility failed to ensure a dignified experience for a resident, identified as Resident #24, who was observed multiple times with food and crumbs on their chin and gown after meals. Resident #24 had a history of moderate cognitive impairment and required supervision or touching assistance for eating and personal hygiene. Despite these needs, the resident was repeatedly observed with food residue on their face and clothing, indicating a lack of appropriate post-meal care. Interviews with facility staff, including a Certified Nurse Aide and the Director of Nursing, revealed that the expectation was for residents to have their face and hands cleaned after meals if needed. However, observations showed that this standard was not consistently met for Resident #24, as they were left with food remains on their clothing and face after meals. This failure to provide necessary assistance and maintain the resident's dignity was a deficiency identified during the recertification survey.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 P(NAME) F 550 I. Immediate Corrective Action: 1) Resident # 24 has been provided with assistance during all meals. The resident’s CCP was revised to reflect her preferences. Nursing Instructions related to this were carried over to the CNAAR. 2) Resident # 24 CCP and CNAAR were reviewed to ensure the correct ADL care was being provided. 3) The SW interviewed resident #24 to identify the presence of any negative psychosocial outcomes related to the incident and none were noted or reported. II. Identification of Others: 1) The facility maintains the position that all residents were potentially affected. 2) All residents CCP’s and CNAAR’s will be reviewed by the Nursing Department to determine if assistance was needed during meals. All residents who have been determined to need assistance with ADL’s during meals will be placed on the CNA’s assignment sheets moving forward. III. Systemic Changes: 1) The DNS reviewed the Policy and Procedure for Residents Rights and found same to be in compliance. 2) All Nursing Staff received Inservice on the Resident Rights specific to residents right to respect and dignity. Highlights of the lesson plan include: - Residents have the right to a dignified experience. Ensuring a resident has an Apron or is given the appropriate assistance in line with the CNAAR. - The Responsibility of the Nursing Aides to routinely check if residents on their assignments are well maintained and free of an undignified experience. - The Responsibility of the Nursing Aides to ensure that all residents including independent residents are cleaned up after meals. IV. Quality Assurance: 1) An audit tool to monitor compliance ensuring that residents are well maintained and free of an undignified experience. 2) Residents will be audited by the RN Managers weekly x 4 weeks followed by monthly x 11 months. 3) Any findings will be corrected by the auditor immediately and brought to the quarterly QAPI meeting. V. Person Responsible: Director of Nursing