F0550

D

Failure to Maintain Resident Privacy and Dignity During ADL Care

Manchester, Connecticut Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to maintain a resident’s privacy and dignity during the provision of ADL care. Resident #2 had Alzheimer’s disease, a BIMS score of 3/15 indicating severe cognitive impairment, no behaviors, and was dependent on staff for toileting, bed mobility, and personal hygiene. The resident’s care plan and NA care list directed assistance of one staff for bed mobility, personal hygiene, and total dependence for brief changes at bed level, with instructions to protect sensitive skin and avoid scrubbing. During a surveyor observation, NA #1 was providing ADL care at the bedside while the room door and bedside curtain facing the hallway were left open, leaving Resident #2 fully visible from the hallway.

The surveyor observed Resident #2 lying supine in bed, undressed, without a shirt or pants, and not covered by any sheet, blanket, towel, or bath blanket. The resident’s chest was exposed, and NA #1’s body only partially blocked the view of the hips/groin area. The surveyor further observed NA #1 pulling and tugging a moderately to heavily saturated adult brief out from under the resident’s hips while the resident remained flat on their back; NA #1 was not heard asking the resident to roll over or lift their buttocks during the brief removal. Subsequent interviews with NA #1, an LPN, the ADNS, the Administrator, and the DNS confirmed that facility expectations and the resident’s rights required closing the door and/or privacy curtain during personal care and that briefs should not be pulled or tugged out from under a resident lying flat, particularly given the need for gentle skin care. The facility’s Residents’ Rights policy also stated residents had a right to privacy when receiving personal and medical care and treatment.