Failure to Ensure Privacy During Personal Care and Treatment Procedures
Penalty
Summary
The facility failed to provide adequate privacy during personal care and treatment procedures for two residents. In the first instance, a resident with Alzheimer's disease and dementia, who was dependent on staff for all activities of daily living and rarely able to communicate, was transferred to bed by two CNAs. Although the privacy curtain was closed from both sides, it was not fully extended to the front of the bed, leaving the resident visible to anyone entering the room or restroom. The CNAs proceeded to change the resident's incontinence pad and reposition the resident while the curtain remained partially open. One CNA acknowledged that the curtain should have been completely closed to protect the resident's privacy. In the second instance, a newly admitted resident with cardiomegaly and chronic respiratory failure was observed during an assessment by a Treatment Nurse. The resident's room door was closed, but the privacy curtain was left open, and the resident was uncovered, with their gown pushed up and incontinence brief exposed. The resident was visible from the doorway. The Treatment Nurse admitted to not closing the privacy curtain during the assessment, despite the resident being exposed. The facility's policy requires staff to promote and protect resident privacy during personal care and treatment procedures.
Plan Of Correction
F-tag 550 Resident Rights/Exercise of Rights Immediate corrective action: On 5/2/25, DON provided 1:1 retraining and reeducation to CNA 8, CNA 14, and Tx Nurse regarding Resident's rights/Privacy and Dignity policy and procedure, emphasizing the importance of providing privacy during personal care and treatment by completely closing the privacy curtain and not visible to any staff or Resident who enters the room to promote, maintain, and protect resident's privacy. Resident 45 and Resident 202 were visited by Social Service on 5/2/25; there were no signs of emotional distress noted. Identification of others at risk: DON/DSD made random rounds on 05/02/25 and 05/20/25 to ensure the residents are provided with privacy during personal care and treatment. No other residents were identified with this same deficient practice. Process to prevent recurrences: In-services by the DON/DSD were provided on 05/02/25 and 05/20/25 to nursing staff to reinforce the policy of resident's rights, privacy, and dignity. Monitoring process: The DON/DSD will conduct weekly random checks for 3 months to ensure nursing staff are providing privacy during personal care and treatment. The Administrator will conduct monthly reviews of findings. Any deficient practices identified will be discussed during the monthly CQI/QA meeting for further recommendations. Completion date: 5/20/2025 F 550