Failure to Assist Resident with Dressing for Appointment
Penalty
Summary
A facility failed to ensure that a resident was treated with respect and dignity by not assisting him with getting dressed in his personal clothing prior to leaving for a medical appointment. The resident, who had diagnoses including acute kidney failure, type 2 diabetes, and a colostomy, was cognitively intact and had 'street clothes' provided by a family member for the appointment. Despite this, the resident was sent to the appointment wearing a hospital gown, which led to feelings of embarrassment. The family member reported the incident, expressing concern about the resident's emotional well-being. Interviews and record reviews revealed that the CNA offered the resident the option to change into his clothes only once, and upon the resident's refusal, did not document the refusal or notify the charge nurse as required by facility policy. The facility's policies emphasized the importance of treating residents with dignity and supporting their rights, including the right to wear preferred clothing. There was no documentation in the clinical record of the resident's refusal or any communication to responsible parties regarding the incident.
Plan Of Correction
F-tag 557 1. Corrective Action for residents found to have been affected: • Resident 1 was discharged from the facility and admitted to Long Beach Memorial Medical Center on 5/30/2025. Resident did not return to the facility. DSD held a 1:1 verbal counseling with responsible CNA on 05/30/2025. The DSD started an in-service to staff including licensed vocational nurses and certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment, started on 05/30/2025. II. Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • On 6/18/2025, the DON conducted a visual audit of residents who went out for appointments to ensure they were dressed in their own personal clothing. On 6/18/2025, one resident went out for an appointment, and she was wearing her own personal clothing when she went to the appointment. No findings were identified. • The DSD started an in-service to staff including licensed vocational nurses and certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment, started on 05/30/2025. • The DSD conducted an additional in-service to certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment on 7/2/2025. • The DON conducted an additional in-service to licensed vocational nurses on 7/1/2025 regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment. III. Facility measures and systemic changes to ensure the deficient practice does not recur: The DSD started an in-service to staff including licensed vocational nurses and certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment, started on 05/30/2025. The DSD conducted additional in-service to certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment on 7/2/2025. The DON conducted an additional in-service to licensed vocational nurses on 7/1/2025 regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment. The DSD/designee will conduct audits that residents will go to their appointment wearing their own personal clothing/appropriate clothing by providing a visual check on a random day of the week, weekly for 1 month, then monthly for 90 days. The DSD will be notified of the scheduled appointments by reviewing residents' orders on the computer system. If the residents are not dressed appropriately during the visual check on a random day of the week/monthly, the DSD/designee will report the findings to the DON, and the DON/designee will provide an in-service to staff including certified nursing assistants and licensed vocational nurses. IV. Facility's plan to monitor corrective actions to achieve and sustain compliance; integrate the POC into the QA process: The DSD/designee will conduct audits that residents will go to their appointment wearing their own personal clothing/appropriate clothing by providing a visual check on a random day of the week, weekly for 1 month, then monthly for 90 days. The DSD will be notified of the scheduled appointments by reviewing residents' orders on the computer system. If the residents are not dressed appropriately during the visual check on a random day of the week/monthly, the DSD/designee will report the findings to the DON immediately. Thereafter, the DON/designee will provide immediate re-education through an in-service to staff including certified nursing assistants and licensed vocational nurses, and implement progressive discipline if repeated to ensure compliance. The DSD/designee will report findings from the conducted weekly/monthly audits that residents will go to their appointment wearing their own personal clothing/appropriate clothing during the monthly QAA meeting for 3 months. Compliance Date: 07/07/2025