Resident Dignity Compromised During Shower Transfer
Penalty
Summary
A resident with diagnoses including Alzheimer's Disease, Anxiety, Schizoaffective Disorder Bipolar Type, and severe cognitive impairment was observed being transported by two CNAs from his room to the shower room while reclined in a mesh slatted shower chair. The resident was only covered by a thin bath blanket, leaving his left shoulder, trunk, buttock, and thigh visible. During this transfer, the resident was pushed past the nurse's station where other residents and staff were present, resulting in exposure. Interviews revealed that staff routinely undressed the resident in his room before transporting him to the shower room, citing the difficulty of transferring him once inside the shower room. The resident's Power of Attorney stated that the resident, a former minister with a history of modesty, would not have appreciated being unclothed in public. The facility's administrator confirmed that residents should be appropriately covered during transfers and that the shower room could accommodate necessary equipment for dressing or undressing. Facility policy requires residents to be treated with dignity and respect, which was not upheld in this instance.