Failure to Promote Resident Dignity During Meal Service and Room Entry
Penalty
Summary
The facility failed to promote resident dignity in two key areas: meal service and staff entry into resident rooms. Observations revealed that residents, including one who was cognitively intact and had chronic respiratory failure and polyneuropathy, were served meals with only plastic, aluminum-sealed juice containers and paper milk cartons, without any cups or glasses provided. This practice was confirmed by the Director of Dietary, who stated that residents are not given cups or glasses with meals. One resident expressed dissatisfaction with this arrangement, stating a preference for a cup and discomfort with drinking from containers that others touch. Additional observations confirmed that meal trays throughout the unit lacked appropriate drinkware. Surveyors also observed multiple instances where staff, including LPNs, CNAs, housekeeping aides, and a contracted nurse practitioner, entered resident rooms without asking permission, despite sometimes knocking or announcing their presence. In several cases, staff entered rooms while residents were present, and in one instance, a staff member entered without knocking. During an interview, the Director of Nursing confirmed that the expectation is for staff to knock and ask permission before entering resident rooms. These actions were reviewed with facility leadership and management representatives during the exit conference.