Failure to Maintain Resident Bodily Privacy in Common Area
Penalty
Summary
Surveyors identified a failure to maintain a resident's bodily privacy and dignity when a resident with severe cognitive impairment and multiple psychiatric and neurological diagnoses was observed partially undressed in a common area. On 12/11/25 at 10:14 AM, the resident was sitting on the floor in a common area across from the nurses station, in front of the elevator, with pants pulled down to the knees and the penis not contained in the incontinence brief. The Social Services Director was seated at the nurses station with his back to the resident and was texting the DON while the resident remained on the floor undressed. At 10:16 AM, a CNA exited the elevator, observed the resident on the floor, and alerted the Social Services Director; together they assisted the resident to stand, at which time the resident’s penis was fully exposed outside of the incontinence brief. The resident’s admission record showed multiple diagnoses including encounter for surgical aftercare, autistic disorder, epilepsy, dementia, schizophrenia, impulse disorder, and intellectual disabilities. The MDS dated 10/05/25 documented severe cognitive impairment and behavioral symptoms that intruded on the privacy of others and disrupted care or living arrangements. Progress notes dated 12/11/25 at 10:53 AM described the resident as being in and out of other residents’ rooms, unable to be redirected, pushing past staff, and laying on the floor exposing self. The facility’s Dignity policy, revised 01/25, stated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, and that staff shall promote, maintain, and protect residents’ privacy, including bodily privacy during assistance with personal care and treatment procedures. Despite this policy and the known behavioral history, the resident was allowed to remain in a public common area with genital exposure until discovered by the CNA.
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