Failure to Honor Resident Dignity, Privacy, and Rights to Services
Penalty
Summary
The facility failed to maintain resident dignity and privacy in several instances. One resident with a neurogenic bladder and an indwelling urinary catheter was observed multiple times with their urinary drainage bag visible from the hallway and door side of the bed, without a dignity cover in place. Staff acknowledged that a dignity cover should have been used, but the issue persisted over several days. Another resident, dependent on staff for most activities of daily living and with a diagnosis of obstructive and reflux uropathy, reported ongoing issues with their roommate tampering with their mail. Despite repeated requests and documentation in the electronic health record for mail to be delivered directly to them or inside their room, mail continued to be left outside the room. Staff interviews revealed a lack of awareness of the resident's request and a breakdown in communication, resulting in the resident's mail privacy not being honored. The facility also failed to ensure residents' rights to attend medical appointments. Two residents missed important medical appointments because the facility was unable to provide an escort due to staff call outs. In one case, a resident's surgery consultation was canceled and not yet rescheduled, and in another, a resident who did not require an escort still had their appointment canceled. Additionally, a resident was left waiting for 24 minutes in the dining area without being served a meal, ultimately leaving the dining room without eating. Staff confirmed that meals should be served promptly upon seating, and the delay was not acceptable.