Failure to Maintain Resident Privacy and Dignity During Personal Care
Penalty
Summary
The facility failed to maintain resident privacy and dignity for four residents during personal care activities, as observed and documented by surveyors. In multiple instances, certified nursing assistants (CNAs) provided incontinence care or toileting assistance without ensuring that window blinds, privacy curtains, or room doors were closed, resulting in residents being exposed to view from outside the building or to their roommates. For example, one resident with severe cognitive impairment and total dependence on staff for toileting was left exposed to the outside patio and parking lot during incontinence care, as the blinds and privacy curtain were not closed. Another resident, cognitively intact but dependent on staff for toileting, was also exposed to the outside during care, and expressed that she would be embarrassed if her private areas were visible to others outside her room. Additional incidents included a resident being assisted with toileting in a bathroom with the door open, exposing his buttocks and scrotum to his roommate, who later stated discomfort with witnessing such exposure. Another resident with severe cognitive impairment and frequent incontinence was left with his perineal area exposed during care, as both the blinds and curtain were left open until a CNA realized and closed the blinds. In each case, the facility's own policy required staff to provide privacy and avoid unnecessary exposure during personal care, but these procedures were not consistently followed. Residents involved had significant medical conditions such as cerebral infarction, dementia, hemiplegia, and morbid obesity, and were dependent on staff for activities of daily living, including toileting and incontinence care. Interviews with residents and family members confirmed that such exposure would be embarrassing and was not acceptable to them. Staff and the Director of Nursing acknowledged that privacy should be maintained at all times, including closing blinds, curtains, and doors during care, but these expectations were not met during the observed incidents.