Failure to Document Resident Privacy Concern During Shower Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, resulting in a lack of documentation regarding a reported privacy violation during a shower. The resident, who was cognitively intact and able to clearly express her concerns, reported that while taking a shower, a male individual entered the shower room, leaving her feeling exposed and violated. The resident stated that she had previously complained about privacy issues, including staff not knocking before entering rooms, and specifically reported this incident to the nurse on duty and to the Social Service Director. The shower room in question did not have privacy curtains, and the resident expressed feeling unprotected and vulnerable as a result. Despite the resident's report and the acknowledgment by staff that the incident occurred and that the shower room lacked privacy curtains, there was no documentation of the incident or the resident's concerns in her medical record. The Social Service Director and the DON both indicated that they did not consider the event an incident requiring documentation, and only a general concern form and an in-service related to shower room safety were completed, neither of which addressed the specific privacy concerns raised by the resident. The lack of documentation and failure to record the resident's expressed feelings and the details of the event constituted a deficiency in maintaining accurate and complete resident records in accordance with professional standards.