Failure to Maintain Resident Dignity and Provide Consistent Dining Assistance
Penalty
Summary
The facility failed to ensure a resident's right to a dignified existence and self-determination by not providing adequate clothing coverage and not ensuring a dignified dining experience. On two separate occasions, a resident who was dependent on staff for dressing was observed in a common area wearing a hospital gown that was not properly tied, resulting in exposure of the resident's back, upper arm, chest, and incontinence brief. The resident was left in this state in the dining room, visible to other residents, staff, and from the hallway, without timely intervention from staff to address the exposure. During a lunch meal, the same resident, who required assistance with eating, did not receive consistent support from staff. The resident was left partially exposed while being assisted with eating, and staff did not adjust the gown to maintain the resident's dignity. Additionally, the resident's drink preferences were not determined or honored, as staff were unsure how the resident preferred their coffee and did not seek clarification from the resident's health care proxy, despite the resident's communication limitations. The resident had a history of dementia, bilateral hearing and visual loss, and was at risk for nutritional decline, requiring staff to determine food and beverage preferences and provide consistent assistance. The facility's own policies and the resident's care plan called for maintaining normal living patterns, explaining procedures, and ensuring proper coverage and assistance, but these were not followed, resulting in repeated lapses in dignified care.