Failure to Maintain Resident Dignity in Common Area
Penalty
Summary
Surveyors identified a deficiency related to resident dignity when a dependent resident with severe cognitive impairment was observed in a common TV area wearing only a green hospital gown with a white sheet over her lap. The resident’s EMR documented diagnoses including Alzheimer’s disease, dementia, aphasia, anxiety, pain, and major depressive disorder, and her most recent MDS showed a BIMS score of 0, indicating severely impaired cognition, and dependence on staff for all ADLs. While seated in a Broda chair in the TV room, the resident moved her hands up and down, raising her sheet and gown so that her white incontinence brief became visible to two male residents seated in the same area. Staff interviews confirmed that this situation was inconsistent with facility expectations and policy. A CNA stated the resident should have been dressed or completely covered and that residents should not be exposed to other residents. A licensed nurse stated residents should not be in the TV room wearing only a gown and sheet and should remain in their rooms until the bath aide was ready for them. An administrative nurse stated facility protocol required residents to be dressed and groomed before leaving their rooms, that residents should be fully dressed when in the TV area, and that incontinence briefs should never be exposed. The facility’s Resident Rights Policy documented that all residents have the right to a dignified existence and that all staff are responsible for protecting those rights, underscoring that the observed exposure of the resident’s incontinence brief in a public area constituted a failure to ensure dignity.
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