Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
A resident with severe cognitive impairment, Parkinson's Disease, major depressive disorder, muscle weakness, and an overactive bladder was dependent on staff for all activities of daily living, including dressing, personal hygiene, and toileting. The resident exhibited behaviors such as wandering, rejection of care, and undressing, and was noted to have poor judgment, safety awareness, and memory recall. The care plan acknowledged behavioral challenges and refusal of care but did not include specific interventions related to the resident's preference or behaviors regarding undressing. Multiple nursing notes documented incidents where the resident was found naked in his room, either standing in the restroom or lying in bed without clothing or covers, and at times refused staff assistance to redress or provide care. Observations confirmed the resident was left uncovered and visible from the hallway and exterior windows for extended periods. Staff interviews indicated awareness of the resident's preference to be undressed but revealed inconsistent efforts to maintain the resident's dignity by ensuring privacy or covering him. The facility's dignity policy required maintaining each resident's dignity and respect, but the lack of individualized care plan interventions and insufficient measures to prevent exposure led to a failure to provide a dignified care environment.