F0550

E

Failure to Maintain Resident Dignity, Privacy, and Respectful Assistance

Hazel Crest, Illinois Survey Completed on 08-14-2025

Penalty

No penalty information released

Summary

The deficiency involves multiple failures to uphold resident dignity and privacy, including improper handling of urinary catheter drainage bags, lack of appropriate clothing, failure to use privacy curtains, and undignified feeding assistance. One resident with cognitive impairment and an indwelling urinary catheter was observed in bed with an uncovered urinary drainage bag hanging from the bed frame, containing approximately 1500 ml of dark amber urine with large sediment. The resident stated that staff only sometimes covered the bag. An LPN confirmed at the time of observation that the catheter bag was not covered and acknowledged that urinary catheter bags should be stored in a privacy bag or otherwise covered to maintain dignity, consistent with facility policy requiring drainage bags to be stored in a privacy bag.

Another resident with cognitive impairment, an unhealed pressure ulcer, and an indwelling urinary catheter was also observed lying in bed with an uncovered urinary drainage bag hanging from the bed frame, containing approximately 300 ml of straw-colored urine. When asked about the uncovered bag, this resident was unable to provide an explanation. The DON later affirmed that urinary drainage bags must be stored in a manner that promotes resident dignity and privacy and that residents should have a privacy bag even when in their rooms. Additionally, a resident with legal blindness, cognitive impairment, and a care plan requiring substantial/maximal assistance with eating was observed being fed by a CNA who stood over the resident rather than sitting at eye level. The CNA acknowledged awareness that staff should be seated at eye level when assisting with meals, as required by facility policy, but stated they were also acting as a sitter for two other residents.

Further dignity concerns were identified involving two roommates. One cognitively intact resident was observed from the hallway using only a thin blanket for coverage and reported having no clothes, stating that they had to go to the nurse’s station naked and walk around the facility without clothing because none were available. No clothing was observed in this resident’s room. At the same time, the roommate was seen from the hallway sitting in a wheelchair with no pants on and an incontinence brief fully exposed, with no privacy curtain drawn or other measures used to maintain bodily privacy. A CNA assisting the roommate with dressing confirmed assignment to both residents, acknowledged that the cognitively intact resident was naked under the blanket due to lack of clothes, and stated that when assigned to this resident they had to search laundry for spare clothing that might fit. The CNA then obtained pants, a shirt, and an incontinence brief from the linen cart and placed them on the resident’s bed. These observations conflicted with the facility’s dignity and resident rights policies, which require staff to promote bodily privacy, respect, and a positive self-image.