Failure to Maintain Resident Privacy During Bed Bath: A resident with dementia, a femur fracture, and limited mobility was observed during a bed bath lying in bed undressed from the waist down, uncovered, and exposed while the CNA left the room to get supplies. The privacy curtain was not used, the door was open, and the resident’s private area remained exposed while the bath was in progress.
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.
Uncovered urinary catheter bag. A resident with an indwelling suprapubic catheter was observed with an uncovered urinary catheter bag. The resident’s record showed neurogenic bladder and an order for catheter care with placement and patency checks every shift. An LPN stated that a privacy bag was always required and acknowledged that no privacy bag was present, while the facility policy did not address covering catheter bags.
A resident who needed feeding assistance was observed being fed by a CNA while the CNA was standing, then later sitting behind and to the right of the resident. The CNA stated staff should be seated beside or facing the resident during feeding, and the LPN/UM and DON both stated staff should sit while feeding residents for dignity and to maintain direct eye contact during meals.
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.
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