Repeated Failure to Ensure Resident Dignity During Meal Service
Penalty
Summary
The facility failed to implement effective actions through its Quality Assurance and Performance Improvement (QAPI) program to address previously identified quality deficiencies related to resident dignity. During a prior recertification survey, the facility was cited for not ensuring dignity when a resident's indwelling urinary catheter drainage collection bag was not fully covered with a privacy bag. In the most recent survey, a similar deficiency was identified under F550 (Resident Rights), where a resident was not provided with a meal tray in a timely manner during dining. The resident was seated at a table for two in the dining room, and while her table mate was served and had started eating, she was left without a meal tray. Observations, interviews, and record reviews confirmed that the QAA committee, which includes interdisciplinary members and meets monthly, had not ensured that effective corrective actions were implemented to prevent recurrence of dignity-related deficiencies. Despite the facility's policy outlining systematic processes for evaluating care and addressing root causes, the repeated citation indicates that the measures in place were insufficient to ensure all residents received dignified care, particularly during meal service.