Failure to Protect Resident Privacy and Dignity: During a resident council meeting, two RA staff entered without knocking, one resident was rushed to the meeting before washing their face, and residents reported staff often entered rooms without permission. During incontinence care, a resident said the privacy curtain did not fully cover the area, and the IPN proceeded with care with help from a male CNA.
Dining trays were not served at the same time to residents seated at the same table in the 100 Unit dining area. A resident was left waiting while another resident at the same table was already being fed by staff, and the resident asked if they were going to eat their noon meal. The CNA and DON both stated that residents seated together should receive meals at the same time for dignity, and facility policies called for dignified communal dining and resident respect.
A nurse administered meds to a resident while the resident was seated on the toilet in the lavatory, rather than waiting until the resident was in a more appropriate setting. The resident had dementia with a BIMS score of 0, and the care plan did not address med administration in the lavatory. The DON stated this was not appropriate, and the facility’s dignity policy prohibited demeaning practices and required staff to treat cognitively impaired residents with dignity and sensitivity.
A resident with dementia, a trach, feeding tube, and biliary drain was repeatedly observed uncovered or partially uncovered in bed, with exposed body parts, a twisted gown, sputum at the trach site, and a drainage bag visible from the hallway. The record showed the resident needed help with ADLs, hygiene, dressing, and dignity measures, and staff interviews confirmed that doors/curtains should be used and drainage bags covered, but these expectations were not consistently met.
A resident with bipolar disorder, chronic pain syndrome, edema, neuralgia, and neuritis, and with a BIMS of 15/15, was observed being transported backwards in a recliner chair from the hallway to the lounge area. The CNA acknowledged residents should be moved forward facing, and the LPN/UM, DON, and LNHA all stated that pulling a resident backwards was not appropriate and was a dignity issue.
A resident receiving ADL care was left uncovered with the curtain open, the door accessible to others, and the bed left in a high position while an aide stepped out to get a brief. Two other severely cognitively impaired residents were transported in recliner chairs facing backward by an LPN and an aide, even though both staff acknowledged residents should be moved forward facing. Interviews with the LPN/UM and DON confirmed that privacy, coverage, lowered beds, and forward-facing transport were expected for resident dignity.
Failure to maintain resident dignity during meal service. A resident with dementia, dysphagia, and Parkinson's disease was observed eating breakfast in bed with bare hands while struggling to handle food, despite needing meal assistance. In the dayroom, another resident with severe cognitive impairment had an uncovered lunch tray left in front of them for more than 30 minutes before staff assisted and reheated the meal, while a CNA assisted another dependent resident with gloves on and conversed with another CNA during the meal. In a separate breakfast observation, a CNA placed a tray in front of a resident and left the meal setup incomplete.
Failure to Preserve Resident Dignity, Privacy, and Autonomy: A resident who was his/her own responsible party was not allowed to leave on pass without an escort despite having a physician order, another resident was observed wearing a visible DNR wristband after admission, and a third resident was denied normal privacy when staff entered the room without knocking. The third resident also reported being drug tested after an overnight visit and not being told the screen could be refused, after which the resident said future visits were restricted.
Dignity and Respect Deficiencies in Incontinence Care and Dining: A resident was observed in bed wearing two incontinence briefs, and staff acknowledged residents are not supposed to be wearing two briefs. The resident had dementia and was always incontinent of bowel and bladder, but the care plan did not include interventions related to the issue until it was brought to the facility’s attention. In addition, residents in multiple dining areas were served meals on trays, with no tablecloths on the tables, and an LPN stated this was not conducive with a homelike environment.
A cognitively intact resident with a left shoulder fracture told an RN that they did not want any male caregivers, and the RN assured the resident this preference would be honored. However, the preference was not documented in the medical record, not added to the care plan, and not communicated in shift-to-shift reports. As a result, a male CNA provided care to the resident, and leadership later confirmed they were unaware of the preference and that the failure to follow it occurred at the nursing level, despite facility policy allowing residents to choose healthcare providers consistent with their interests and personal care needs.
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