Failure to Ensure Dignified Room Entry and Dining Experience
Penalty
Summary
Staff failed to honor a resident's right to a dignified existence and self-determination by not knocking or announcing themselves before entering a resident's shared room. On multiple occasions, a nursing assistant entered the room without knocking, and the resident confirmed not hearing a knock and expressed feeling vulnerable as a result. Interviews with other staff, including a registered nurse and the assistant director of nursing, confirmed that the expectation was for staff to knock and announce themselves before entering, in accordance with the facility's policy on dignity, which requires staff to respect residents' private space and request permission before entry. Additionally, the facility did not provide a dignified dining experience for residents. Observations revealed that meals were consistently served to all residents in the dining rooms on hard plastic trays, with food, drinks, and utensils left on the trays rather than being placed on the tables. Staff reported that this was the standard practice, and no efforts were made to remove items from the trays or offer residents a choice in how their meals were served. Some staff believed serving on trays was more dignified, but could not explain why, and dietary management acknowledged that while some residents preferred trays, others did not, yet no individualized assessments or care plan updates were made to reflect resident preferences. Interviews with dietary management and facility leadership confirmed that resident preferences regarding meal service had not been assessed or discussed in resident council meetings, and no documentation existed of such discussions. The facility lacked a policy on dignified dining and had not updated care plans to reflect individual preferences for meal service, despite recognizing the importance of a home-like, dignified dining experience for residents.