Resident Dignity Not Maintained When Brought to Dining Room in Exposing Hospital Gown
Penalty
Summary
Surveyors identified a failure to protect a resident’s dignity when a severely cognitively impaired memory care resident was observed seated alone in the dining room wearing only a hospital gown, with his back and legs exposed. The resident had multiple medical diagnoses including unspecified dementia, psychosis, delusional disorder, TIA, depression, anxiety, and significant physical limitations such as muscle weakness, difficulty walking, and unsteadiness. His most recent MDS showed a BIMS score of 0, highly impaired vision, unclear speech, and dependence on staff for all ADLs, including dressing, toileting, and eating. At the time of observation, he had a full breakfast tray in front of him but was not feeding himself. A CNA confirmed that the resident had been brought to the dining room in the hospital gown and stated there was not enough time or staff to get him dressed before breakfast, acknowledging that this was not appropriate attire for the dining room but leaving him uncovered. An LPN reported she believed it was appropriate for residents, particularly skilled residents, to be in the dining area in hospital gowns, while also acknowledging that this resident could not choose how he was dressed due to his cognitive impairment. The resident’s spouse stated she believed staff did everything they could given staffing ratios and that responses could be delayed because staff were busy. The facility’s Dignity, Respect, and Privacy Policy stated that residents were to be treated with respect and cared for in a manner that protected their privacy, but this was not followed in this incident.
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