Failure to Maintain Resident Dignity During Personal Care and Feeding
Penalty
Summary
The facility failed to provide care in a dignified manner for two residents during routine care activities. In the first instance, a resident with end stage renal disease and intact cognition, who was dependent on staff for toileting hygiene, was left exposed during incontinence care. The CNA responsible for the resident left the room with the door open and the privacy curtain not drawn, leaving the resident with their pants and incontinence brief down and their buttocks exposed to the hallway. The CNA acknowledged being aware of the need to provide privacy but admitted to rushing and not following proper procedures. The resident reported being left in this state for more than five minutes and expressed discomfort and dissatisfaction with the lack of privacy. In the second instance, another resident with severe cognitive impairment, hemiplegia, and hemiparesis, who was dependent on staff for eating, was fed by a CNA who stood at the bedside rather than sitting at eye level as required by facility policy. The CNA stated she did not sit because there was no chair available in the room. The resident had to turn their head to receive food and drink, and the staff did not position themselves as directed in the care plan. Other staff members, including an LVN and the DON, confirmed that feeding should be done while seated at eye level to maintain dignity, and that a chair should have been obtained if one was not present. Both incidents were observed and confirmed through interviews with staff, residents, and facility leadership. Facility policies reviewed indicated clear expectations for maintaining resident privacy during personal care and for staff to be seated at eye level when assisting residents with eating. The actions and inactions of the staff in these cases did not align with these policies, resulting in a failure to honor the residents' rights to dignity and proper care.