Failure to Ensure Resident Dignity and Privacy During Care and Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, and that care was provided in a manner that promoted the maintenance or enhancement of their quality of life. Specifically, one resident who was totally dependent on staff for eating, with severe cognitive impairment and dysphagia, was observed being fed by a CNA who interrupted the feeding to use her personal cell phone for three minutes. This action occurred in the assisted dining room, where the resident required full assistance with feeding, and the CNA's attention was diverted from the resident during the meal. Additionally, staff members, including an LVN and another staff member, were observed entering the rooms of three residents without knocking. These residents had varying degrees of cognitive impairment and multiple medical diagnoses, including dementia, heart failure, and mobility issues. Observations confirmed that staff entered rooms and even opened bathroom doors without first knocking or waiting for a response, despite facility policy and staff training requiring them to do so to respect residents' privacy and dignity. Interviews with residents, staff, and facility leadership confirmed that the expectation was for staff to knock before entering resident rooms, except in emergencies. Some residents expressed a preference for staff to knock, while others were indifferent. Staff interviews revealed awareness of the policy, but lapses were attributed to being in a hurry or complacency. The facility's policies on resident rights and cell phone use were reviewed, indicating that staff should not use personal phones while providing direct care, especially during feeding, and that residents have the right to privacy and dignity.