Failure to Maintain Resident Dignity and Timely Assistance With Dressing
Penalty
Summary
Surveyors identified a failure to maintain a resident’s dignity and quality of life when staff left a cognitively impaired resident in bed wearing only an ill-fitting adult brief, with inadequate covering, and visible from the open doorway on multiple occasions. The resident, admitted with diagnoses including non-ST elevation myocardial infarction, encounter for palliative care, weakness, acute on chronic systolic (congestive) heart failure, and hyperlipidemia, had a care plan indicating the need for assistance from one staff member for dressing and an MDS BIMS score of 8, reflecting moderate cognitive impairment. The admission packet and facility policy documented the resident’s rights to dignity, bodily privacy, respect, and an environment that supports individuality, independence, and choice. On one observed date at 1:06 PM, the resident was found lying in bed in only an ill-fitting adult brief with just one flat sheet available for covering, and the resident was visible from the open entry doorway. At that time, the resident reported having waited since 7:00 AM to have pants put on. Later that afternoon at 2:54 PM, the resident was again observed lying in bed with only a sheet half covering the body, the door open, and no clothing other than the adult brief. The resident reported experiencing long wait times for help with dressing a couple of times a week and expressed that staff did not like them. The DON stated that resident requests for care should not exceed a one-hour wait time and that dignity should always be considered, indicating that the observed delays and lack of privacy were inconsistent with facility expectations and written resident rights policies.
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