Dirty Shoulder Immobilizer Not Cleaned Regularly: A resident with a right shoulder immobilizer for recurrent dislocation and ROM support was observed with a dirty, stained brace that wrapped around the trunk. The RN said the brace had not been washed recently and staff only tried to clean it about once a month, while ES staff acknowledged it had not been washed for a while. The brace appeared to have food on it from eating and wiping hands on it, and a VPS verified resident devices should be washed when dirty because it could be an infection control concern.
A resident with moderate cognitive impairment, MS, neurogenic bladder, an indwelling catheter, and a left nephrostomy tube had his nephrostomy drainage bag left uncovered and visible from the hallway while seated in a Broda chair with his room door open. The care plan directed staff to ensure he was appropriately covered and dignity was provided, and the RNCM and DON confirmed the uncovered bag was a dignity concern.
Meals were served to multiple residents on hard plastic trays in the dining room, with the trays left under the plates, beverages, and silverware during the meal. Staff did not remove the trays or offer to do so, and one resident said he did not like eating from the tray. In a separate incident, an NA knocked once and entered a resident’s room without waiting for permission, and the resident stated staff just walk right in and that he did not feel he had adequate privacy.
Failure to provide dignified toileting and incontinence care: Two residents who needed staff help with toileting were not treated respectfully or assisted in a timely manner. One resident waited over 2 hours after asking to be changed and was later found with a urine- and feces-saturated brief and soaked clothing, while staff acknowledged the delay was unacceptable. Another resident reported an NA violently removed her brief and told her to do it on her own, and a separate grievance said the same NA told a resident to use a brief instead of taking her to the bathroom, leaving her without toileting for the shift.
A resident with a urinary catheter was observed ambulating with an uncovered catheter bag hanging from a walker while passing staff and residents in common areas. OT-A said she forgot to move the privacy bag, and the resident stated a preference for the catheter bag to be covered in public areas. RN-A stated catheter bags were to be covered and called it a dignity issue.
Dignified Dining Experience Not Maintained: A facility failed to serve residents seated at the same table at the same time. During lunch and breakfast meal service, one resident waited while tablemates ate, another resident received breakfast after a tablemate had already started eating, and a third resident had to request oatmeal twice before being served. The DON stated meals should be served table by table, while nursing assistants described serving residents by tray readiness or meal ticket order instead.
Delayed response to a resident's call light led to a bladder accident. A resident admitted with post-polio syndrome and BPH was oriented, able to communicate, and had a care plan calling for a call light within reach and a urinal available, but staff did not provide a urinal on admission and multiple staff passed by while the call light remained on. The resident reported using drinking cups to urinate and having wet clothing and a wet floor before help arrived; the administrator later acknowledged the call light had been on for 14 minutes before it was answered.
A resident who was dependent on staff for toileting and transfers, and who was frequently incontinent, was left in bed in only a sweatshirt and brief while crying after staff told her to stay in bed and pee her pants so they could clean her up later. The resident said this happened often and that her call light was frequently turned off. Staff interviews confirmed she should not have been told to remain incontinent, and the DON stated residents should never be told to be incontinent because it is a dignity issue.
A resident with impaired cognition, incontinence, and a catheter for neurogenic bladder had his catheter drainage bag visible in the commons area and later from the hallway, with clear yellow urine showing. Staff, including therapy, the IP, and an RN, did not arrange privacy, and the bag was also hung facing out toward the room entrance. The DON stated staff were expected to keep the blue side of the bag facing the public to cover it and maintain dignity.
Failure to trim a resident’s fingernails during weekly bathing. A resident with cognitive impairment and ADL dependence had very long fingernails on all 10 fingers over several days and stated he could not cut them himself and wanted them trimmed. Staff gave conflicting statements about who could perform nail care, with NAs saying only nurses could cut nails while the RN, CM, and DON stated NAs could trim nails for non-diabetic residents and that nail care should occur with weekly showers when needed or requested.
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