Failure to provide dignified meal assistance: Two residents who were dependent on staff for eating were observed during breakfast with CNAs standing over them at the bedside instead of sitting beside them at eye level. One resident had dementia and a history of aspiration-related pneumonitis, and the other had schizophrenia, dementia, and dysphagia with severe cognitive impairment. The CNAs stated they stood while assisting with meals, while the UM and DON stated staff were expected to sit during physical meal assistance.
Failure to maintain dignity and privacy during clinical care: A physician dictated a resident’s H&P loudly at the nursing station in front of multiple residents and staff, and a hospice nurse completed another resident’s assessment in a common area while others were nearby. Both residents had severe cognitive impairment, and staff interviews confirmed the care should have been done in a private setting.
Failure to Provide Bodily Privacy During Care: Two residents were observed receiving blood draws without privacy, including one in a dayroom with other residents present and another visible from the hallway with the door open. A third resident was observed in bed while an RN applied a pain patch to the lower back with the curtain not pulled and the door wide open, making the resident's body visible from the hallway.
Dignity and Meal Assistance Failures During Shared Dining: Residents seated together in a shared dining room were not served meals at the same time, leaving some residents waiting while tablemates ate. Staff acknowledged this was not dignified. A resident with dementia, severe cognitive impairment, and a care plan for supervised meals was left alone after tray setup and spilled food, dropped utensils, and ate with fingers while staff were not present.
Failure to provide dignified grooming care: A resident with dementia, depression, and severe cognitive impairment was observed with significant facial hair on multiple occasions. The resident said the facial hair was embarrassing and asked for it to be removed, while CNA documentation did not show refusal of care and a nurse stated the facial hair should have been removed with daily care.
Failure to maintain resident privacy during personal care. A resident who was dependent on staff for all ADLs and had dementia, dysphagia, and seizures was observed naked in bed receiving morning care with the privacy curtain open, allowing two roommates to see the resident. The CNA acknowledged residents should have privacy during care, and the DON stated privacy curtains should be pulled during personal care.
Failure to Maintain Resident Dignity During Medication Request: A resident with anxiety and Paranoid Schizophrenia, who was cognitively intact, was observed at the nurse’s station while an RN pointed a finger in the resident’s face and yelled that it was not time for medication and that the resident was harassing her. The resident became tearful and said the nurse did not have to speak that way. The DON later stated the interaction was derogatory and violated the facility’s dignity and respect policy.
Failure to Cover Cholecystostomy Drainage Bag for Dignity: A resident with sepsis due to E. coli and biliary obstruction had a cholecystostomy drainage bag that was observed uncovered and visible during multiple surveyor observations. The resident and family said it had been without a privacy cover since admission, and a CNA, an RN, and the DON all acknowledged it should have been covered for dignity.
Dignified Dining and Improper Positioning During Meal Assistance: A resident with MS, dysphagia, severe cognitive impairment, and dependence on staff for eating was observed receiving breakfast while lying in bed, slouched on one side with the HOB only slightly elevated, while a CNA stood over the resident and assisted with feeding. The resident said the position was uncomfortable, and the DON stated staff are expected to sit at eye level and ensure the resident is properly positioned during meals.
A nurse used a personal cell phone to take photographs of three cognitively impaired, fully dependent residents and texted these images to a non-staff individual, in violation of facility policy on resident images and rights. The photos, later obtained through a BORN investigation and reviewed by the ADON, showed one resident standing fully clothed in a hallway, another sitting on the hallway floor in a johnny and brief, and another lying in bed in a johnny under bed linens. All three residents had documented dementia or related cognitive impairment on recent MDS assessments and were unable to be interviewed.
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