Failure to Maintain Resident Dignity, Privacy, and Respect
Penalty
Summary
Multiple deficiencies were identified regarding the failure to honor residents' rights to dignity, respect, and privacy. In one instance, a resident with severe cognitive impairment and hemiparesis was observed in a public hallway wearing only a t-shirt and incontinence brief, with the brief visible to others, despite being dependent on staff for dressing and mobility. Another resident with dementia and severe cognitive impairment had a sign posted above their bed stating 'I AM A FEEDER,' which was placed by staff to indicate the need for eating assistance. The sign was not requested by the resident or their family and was considered undignified by both the family and facility management. Staff were also observed eating take-out food in a designated resident space (the sunroom) while two residents, both with severe cognitive impairment, were present and eating their lunch. This action was contrary to facility policy, which designated the sunroom as a resident-only area. Additionally, in a four-person room, a resident had to move out of their chair to allow staff to use a mechanical lift for their roommate, resulting in a lack of privacy for the resident being transferred. The limited space in the room prevented staff from maintaining appropriate privacy during the transfer. Interviews with facility leadership confirmed that these actions were inconsistent with facility policy, which requires residents to be treated with dignity and respect, prohibits undignified signage, and mandates the protection of resident privacy, including bodily privacy during care. The Director of Nursing acknowledged concerns about privacy in multi-occupancy rooms and confirmed that staff should not eat in resident spaces or post undignified signs.