Resident Dignity Not Maintained During Supervision Lapse
Summary
A resident with severe cognitive impairment, altered mental status, and a history of restlessness and agitation was observed sleeping at the nurses' station with her head resting directly on the desktop. The registered nurse responsible for her care acknowledged that this positioning was not optimal and did not maintain the resident's dignity, stating that the resident should have been returned to her room to sleep in her bed. The nurse was not in a position to directly supervise the resident at the time she was observed, and another nurse practitioner present stated she was not responsible for the resident but had been helping to keep her calm. The resident's care plan included interventions such as encouraging her to be in common areas when awake, increasing the frequency of checks, and ensuring she was up in a wheelchair in visible fields when rambling. Despite these interventions, the resident was left unsupervised and allowed to sleep in a public area in a manner that did not promote dignity or respect, as required by facility policy. The Director of Nursing confirmed that this did not meet the facility's standards for maintaining resident dignity and that alternative arrangements were available for such situations.
Penalty
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