Failure to Maintain Resident Privacy During Transfer
Penalty
Summary
Staff failed to ensure privacy for a resident with vascular dementia, Tourette syndrome, seizures, and an intracranial injury, who was dependent on staff for all care needs. During a transfer from a shower chair to the resident's room using a mechanical lift, the resident was covered with linens but did not have clothes underneath. Despite attempts to cover the resident, the scrotum remained visible, and the resident's genitals were exposed and viewable from the hallway. The transfer was conducted without the use of a privacy curtain, and the resident was loudly and repeatedly yelling an expletive, which drew additional attention from others in the hallway. Staff interviews revealed that the transfer could not be performed inside the resident's room due to space limitations, requiring all transfers to be conducted in the hallway. The care plan indicated the need for a mechanical lift with two-person assistance for transfers. Facility policy stated that residents have the right to privacy and confidentiality, and the DON confirmed that it was not acceptable for a resident's genitals to be visible in the hallway.