Failure to Ensure Privacy During Wound Care
Penalty
Summary
Facility staff failed to maintain privacy and confidentiality during personal and medical care for one resident. The resident had been admitted to the facility on an unspecified date and had a BIMS score of 5, indicating severe cognitive impairment. The resident’s care plan and clinical profile documented multiple significant medical conditions, including lymphedema, venous insufficiency, osteoarthritis, rheumatoid arthritis, multiple open wounds on the buttocks and lower extremities, pressure ulcers on both heels, severe protein calorie malnutrition, metabolic encephalopathy, and various staged pressure injuries and moisture-associated skin damage. The resident had physician orders for specific wound care to the right and left posterior hips, including cleansing with saline, application of triad paste and silver alginate, and covering with a silicone superabsorbent dressing. During an observation of wound care performed by an RN, the resident’s bed was in a low position with a fall mat beside it, and the resident was lying on their left side. The room did not have a privacy curtain, and it had been missing for a few weeks. While the RN provided wound care, the resident’s roommate was seated at the side of their own bed eating breakfast and was able to see the resident’s exposed buttocks and all personal and wound care being provided. The roommate commented, “nice butt,” and both the resident and the RN laughed before the RN covered the resident with a blanket. In a subsequent interview, the RN confirmed that the lack of a privacy curtain allowed the roommate to view all aspects of the resident’s care and acknowledged this as a breach of the resident’s privacy and dignity.
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