Resident Left Without Linens and Visual Privacy After Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure full visual privacy and dignity for a male resident with severe cognitive impairment. The resident, an older adult male with dementia, pancreatic cancer, anxiety, hypertension, hypothyroidism, depression, frequent falls, and pain, had a BIMS score of 3, indicating severe cognitive impairment. His care plan was in place, and he was admitted with multiple chronic conditions. On the night in question, video evidence showed that at 2:19 AM an LVN entered the resident’s room, which had an open door, to provide incontinence care. During this care, the LVN removed the resident’s sheet and blanket and left him in bed wearing only a shirt and brief, with no linens covering him, and did not close the door or draw curtains. The video further showed that from 2:19 AM until 4:43 AM, the resident remained in this state, with the door open and without bed linens, curtains, or a closed door to provide visual privacy. At 4:43 AM, the LVN returned to the room, with the door still open, and then left again after speaking with a CNA in the hallway. Audio from the video captured the LVN telling the CNA that she had previously instructed the CNA to take care of the resident, and the CNA responding that she had forgotten because she had gotten busy. The CNA then entered the room and provided appropriate clothing and linens, including a fitted sheet, blanket, and top sheet, to cover the resident and restore his privacy and dignity. Staff interviews and written statements confirmed the sequence of events. The LVN’s written statement indicated she found the resident wet, with his penis outside the brief, removed the wet linens and brief, provided perineal care, and expected the CNA to complete the linen replacement. The CNA’s statement confirmed that she was asked to assist but delayed going to the room because she was busy, and when she eventually entered around 4:00 AM, the resident was lying in bed with only underwear, socks, and a shirt, with no linens and the door open so he was visible from the hallway. The administrator, DON, and other staff acknowledged awareness of the incident and that the resident had been left in bed with only a brief and shirt and without linens for an extended period, during which he was visible from the hallway, contrary to the facility’s resident rights policy and posted resident rights materials regarding dignity and respect.
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