Failure to Ensure Resident Dignity During Care and Dining
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect during both incontinence care and dining. Observations revealed that staff performed incontinence care on a resident with moderately impaired cognition and substantial assistance needs without closing the door or pulling the privacy curtain, leaving the resident exposed from the waist down and visible from the hallway. Staff interviews confirmed that the door remained open during the care, and facility leadership acknowledged that privacy measures should have been in place according to the facility's admission agreement, which guarantees privacy during personal care. Additionally, staff were observed placing clothing protectors on three residents with varying degrees of cognitive impairment and assistance needs for eating, without asking for their consent or confirming if it was care planned. Interviews with CNAs and the Administrator revealed that clothing protectors were routinely applied to protect clothing, regardless of resident preference or documented need, and there was no facility policy guiding their use. The facility's admission packet states that residents have the right to be treated with courtesy, respect, and full recognition of their dignity and individuality.