Failure to Maintain Resident Dignity and Privacy During Care and Unauthorized Recording
Penalty
Summary
The deficiency involves failures to honor residents' rights to dignity, respect, and privacy. For one resident with severely impaired cognition, a history of stroke with right-sided weakness, non-Alzheimer's dementia, and seizure disorder, surveyors observed that after lunch the CNA transported the resident to her room and positioned her in a wheelchair facing the open doorway with mashed potatoes left below her left lower lip. Over 30 minutes later, the resident remained in the same position with food still on her face, despite her care plan indicating she required assistance with eating on days she was more tired and that staff were to perform oral hygiene. Staff later acknowledged that leaving food on a resident's face when they are put in their room is a dignity concern. On a separate occasion, the same resident was observed in a dining conference room with her gown positioned so that her right shoulder, collar-bone, and the nape of her neck were fully exposed while being assisted with eating. After being transported back to her room, the CNA briefly pulled the gown over the resident's right shoulder and left, but the gown slipped back down, again exposing the same areas. Later that morning, the resident was transported to the lobby for a group activity with her gown still positioned below her right shoulder, exposing her shoulder, collar-bone, and neck in a public area with other residents present. Multiple staff members stated that leaving food on a resident's face and having a female resident's shoulder, collar-bone, and neck exposed in a public setting are dignity concerns, and the DON stated staff should have assisted the resident to clean her face and readjust her clothing. A separate deficiency involved the DON recording another resident without the resident's knowledge or consent. This resident, who had moderate cognitive impairment per the MDS, reported that the DON and the MDS coordinator came into her room and argued with her about alleged cameras in the room, accusing her of recording staff. The resident stated that a police officer later told her the DON had recorded their interaction, and she felt that being recorded without her knowledge was very upsetting and disrespectful. Staff interviews confirmed that the DON entered the room with the MDS coordinator and recorded the entire encounter using her personal phone, which she placed in her pocket, without informing or asking permission from the resident. The DON acknowledged there was no facility policy for staff recording residents and that she saw a dignity issue with recording the resident without her knowledge, despite existing facility policies prohibiting staff from taking or using photographs or recordings in a manner that would demean or humiliate residents and requiring protection of PHI under HIPAA/privacy safeguards.
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