Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain resident dignity in two separate instances involving two residents. In the first case, a resident with a history of falls, major depressive disorder, and type 2 diabetes mellitus, who was cognitively moderately impaired and required assistance with hygiene, had an indwelling urinary catheter. During observation, it was noted that the resident's urinary catheter bag was not covered with a privacy bag, contrary to facility policy and staff statements that such coverage is required to promote dignity. Both the MDS Coordinator and Assistant Director of Nursing confirmed that the catheter bag should have been covered, and the facility's policy explicitly stated that privacy bags must be used at all times for catheter drainage bags. In the second instance, another resident with type 1 diabetes mellitus, end stage renal disease, and a below-knee amputation, who required moderate assistance for bathing, reported that staff did not knock before entering the shower room while he was showering. The resident stated that staff entered multiple times to drop off soiled linens without knocking, which he felt violated his dignity and privacy. The CNA assisting the resident confirmed that several staff members entered the shower room without knocking, and the Director of Nursing acknowledged that staff are required to knock before entering any room occupied by a resident to preserve privacy and dignity. Both incidents were found to be inconsistent with the facility's policies on promoting and maintaining resident dignity, which require staff to treat residents with respect, ensure privacy, and use privacy bags for catheter drainage. The deficiencies were identified through interviews, record reviews, and direct observation, with staff and leadership confirming the expectations and acknowledging the lapses.