Failure to Ensure Resident Dignity and Respect in Care Environment
Penalty
Summary
The facility failed to maintain a dignified care environment for several residents, as evidenced by multiple observations of residents with severe cognitive impairment being exposed or undressed in public or semi-public areas. One resident was repeatedly observed with her pants and briefs pulled down and touching the inside of her briefs in a room near the dining area, rather than in her own bedroom. Another resident was seen walking with her hand down her shirt, exposing her upper chest, without staff present to assist. Staff were also observed placing a clothing protector on a resident at the dining table without asking or speaking to her, and another resident was pulled away from an activity and taken to bed without being consulted or spoken to about her preferences. Additionally, there were incidents where residents' interactions during meals were not managed in a way that preserved dignity. One resident began grabbing food from another's tray, prompting the second resident to leave the table in frustration. Interviews with staff confirmed that residents were expected to be fully clothed in public areas and that staff were supposed to ask permission before providing care or moving residents. The facility's own behavioral health policy emphasized individualized approaches to care and promoting emotional and psychosocial well-being, which was not reflected in the observed practices.