Failure to Ensure Resident Dignity During Meal Service and Catheter Care
Penalty
Summary
Staff failed to treat residents with dignity in two separate incidents. In the first case, a resident with diagnoses of anxiety, depression, and morbid obesity, and with intact cognition, did not receive a breakfast tray in a timely manner. The resident reported to the nurse that she did not get her breakfast tray after trays were passed, which made her very upset. Staff interviews revealed that the CNA assigned to pass trays was not permitted in the resident's room, and instead of arranging for another staff member to deliver the meal, the resident was left waiting. The Director of Nursing acknowledged that a check-off system should be in place to prevent missed meal trays. In the second incident, a resident with severe cognitive impairment, Alzheimer's disease, multiple sclerosis, and bipolar disorder, who utilized an indwelling catheter, was observed in the dining room on multiple occasions without a dignity cover on the catheter bag. The catheter bag, containing visible dark yellow urine, was exposed in the presence of other residents. Staff interviews confirmed that catheter bag covers were not available in the facility storage, and both nursing staff and the DON stated that covers should be used to promote resident dignity. Facility policy required the promotion and maintenance of resident dignity, including the use of catheter bag covers.