Failure to Maintain Resident Privacy and Dignity During Incontinence Care
Penalty
Summary
Nursing staff failed to maintain resident privacy and dignity during the provision of incontinence care for one resident with severe cognitive impairment and multiple medical conditions, including dementia, stroke, and incontinence. During observed care, staff did not use the privacy curtain between the resident and the hallway door, nor between the resident and a roommate, resulting in the resident being exposed while receiving peri care. In one instance, the door to the hallway was partially opened while the resident's pants were down, further compromising privacy. The resident required substantial to maximal assistance with activities of daily living due to her cognitive and physical limitations. Her care plan emphasized the need to promote dignity by keeping her clean, dry, and free from odor, and included interventions to communicate simply and provide necessary cues due to her confusion and disorientation. Despite these documented needs, staff did not follow facility policy or care plan interventions regarding privacy during care. Facility policy required staff to provide privacy by pulling curtains or closing doors during perineal care and to treat all residents with respect and dignity. Interviews with facility leadership confirmed the expectation that privacy should be maintained during care. However, video evidence and interviews indicated that these procedures were not followed, resulting in the resident being exposed to both the hallway and a roommate during personal care.