Resident Dignity Compromised During Post-Shower Transfer
Penalty
Summary
A resident with quadriplegia, diabetes, and feeding difficulties, who was totally dependent on staff for mobility, transfers, eating, and bathing, was observed being wheeled down the hallway in a shower chair after a shower with their buttocks exposed. The resident was wearing only a hospital gown with no additional covering, and staff, other residents, and the surveyor were able to view the exposed area. The resident's care plan indicated total dependence on staff for bathing and transfers, and the facility's policy required residents to be treated with dignity and to have privacy during personal care. The Director of Nursing (DNS) witnessed the incident and confirmed that the resident should have been fully covered during the transfer. The nursing assistant responsible for the transfer acknowledged awareness of the policy but stated she was in a hurry at the time. The facility's resident rights policy emphasized the right to dignity, respect, and privacy during care, which was not upheld in this instance.