Failure to Maintain Resident Dignity During Blood Glucose Testing, Clothing, and Meal Assistance
Penalty
Summary
The deficiency involves failures to protect and promote resident dignity for two residents. One resident was observed seated at a dining room table while a licensed nurse obtained a blood glucose reading from the resident’s finger in the presence of other residents, a visitor, and staff. On another occasion, the same resident was observed wearing thin, see-through pink pants in the dining room, with her brief visible through the material. She was seen wearing the same see-through pants again the following morning at breakfast, with her brief still visible. The administrative nurse later verified that blood sugar checks should not be done at the dining room table and that the resident should not have been wearing see-through pants due to dignity concerns. The facility’s Residents Dignity policy stated that residents would be treated with respect and dignity and cared for in a manner that promotes maintenance and enhancement of quality of life. The second resident had diagnoses including paraparesis, major depressive disorder, dysphagia, contractures, and polyneuropathy, with documented impairments of both upper and lower body and dependence on staff for all ADLs except eating, for which supervision and touching assistance were required. The resident’s care plan included setup assistance with adaptive equipment, supervision and partial assistance with meals, half portions for weight loss, and mechanical soft diet consistency. During observation, a CNA stood at the resident’s right side and assisted him with eating a bite of bacon rather than sitting next to him. Subsequent staff interviews revealed inconsistent understanding among nursing staff about proper positioning when assisting residents with eating, despite prior in-servicing that staff should sit in a chair and converse with the resident they are assisting. The facility’s Resident Rights and Responsibilities policy documented that residents would be treated with respect and dignity in an environment that promotes maintenance or enhancement of quality of life.
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