Failure to Maintain Resident Dignity and Privacy During Direct Care
Penalty
Summary
Multiple residents were not treated with dignity and respect, as required by facility policy and resident rights, during the provision of direct care. In one instance, a resident with a urinary catheter was observed lying in bed with the catheter bag uncovered and visible from the doorway while family members were present. The urinary bag, filled with urine, was not placed in a privacy bag as required, making it visible to anyone entering the room. Staff, including a Licensed Vocational Nurse (LVN), Certified Nurse Assistant (CNA), Infection Preventionist (IP), Assistant Director of Nursing (ADON), and Director of Nursing (DON), all acknowledged that the catheter bag should have been covered to maintain the resident's dignity and privacy. In several other cases, staff failed to provide privacy during routine medical procedures. Blood pressure checks were performed on two residents without closing privacy curtains or doors, allowing other residents, visitors, and roommates to observe the procedures. Both the LVN and Registered Nurse (RN) involved admitted that privacy should have been provided. Similarly, blood sugar checks and insulin administration were conducted for multiple residents without ensuring privacy by closing doors or curtains, despite the presence of visitors and other residents in the vicinity. The staff involved recognized these lapses as dignity and privacy issues. Facility policies reviewed during the investigation emphasized the importance of treating residents with dignity and respect, including maintaining privacy during personal care and medical procedures. Staff interviews consistently confirmed that the observed actions did not align with facility expectations or policies. The deficiencies were observed across different shifts and involved multiple staff members, including agency and regular staff, indicating a pattern of failure to uphold resident dignity and privacy during care.