Failure to Ensure Resident Dignity During Care and Postmortem Handling
Penalty
Summary
Facility staff failed to ensure the right to a dignified existence for two residents. One resident, who was blind and had chronic back pain and migraines, was observed traveling independently in a wheelchair to the shower room using wall grab bars for guidance. During this time, the resident was wearing a short hospital gown that was not properly tied, leaving his entire back exposed as he moved through common areas. Staff present did not recognize or address the inappropriateness of the resident's attire outside his room, despite his cognitive abilities being intact and care plan interventions specifying the need for minimal assistance and supervision with activities of daily living. Another resident, who had multiple chronic conditions and no cognitive impairment, expired in the facility. After death, four staff members were observed transporting the deceased resident in a bed covered completely with a gray blanket, including the head and face, to an empty room used for storage. The bed was placed in a cater-cornered position near the door, and the resident was not positioned behind a curtain or in a manner suitable for family viewing. When the blanket was removed, the resident's mouth was open, lips were dry, and hair was uncombed, indicating that postmortem care had not been properly provided as per facility policy, which requires maintaining a good appearance and treating the body with dignity and respect. Interviews with staff and review of facility policy confirmed that the actions taken did not align with expectations for postmortem care or the maintenance of resident dignity. The staff involved did not provide explanations for the manner in which the deceased resident was handled, and facility leadership acknowledged that the observed practices were not appropriate and constituted a dignity issue.