A facility failed to provide dignified meal assistance when 2 staff were observed helping 6 residents at once, leaving some residents waiting while food sat in front of them. Staff reported they could not sit with residents or converse with them because they were assisting too many people, and leadership stated staff should be seated with residents during feeding. In separate observations, CNAs stood while feeding residents for the entire meal and used clothing protectors as napkins, despite care plans calling for feeding assistance and dignified support.
Failure to honor a resident's refusal of a Scopolamine patch. An MA attempted to apply the patch without first explaining the procedure, and the resident showed non-verbal signs of refusal by pulling away, shaking the head, and grimacing. Even after the resident indicated no, the MA held the resident's face and placed the patch anyway. RN stated these were signs of refusal, and the DON acknowledged the MA did not follow standards of care.
A resident with CVA, dysphagia, aphasia, and moderate cognitive impairment was denied an advanced diet unless she ate in the dining room for supervision, despite preferring to eat in her room. She frequently refused pureed meals, had significant weight loss and malnutrition, and staff confirmed she could have a minced diet with supervision. The ST also stated the resident and family were not educated on the risks and benefits of regular-texture foods, and no consent was obtained for eating regular foods in her room without supervision.
Two residents were not treated with dignity and respect in common areas. One resident with MS was observed in a gown with the back and side exposed while being assisted to activities, and staff said the resident preferred a gown and needed help staying covered. Another resident with debility and dementia was observed sitting in the common area wearing only a t-shirt and incontinence brief with the bottom half exposed while staff walked by; a CNA later covered the resident with a blanket, and the NHA acknowledged residents should be dressed appropriately for dignity.
A resident with intact cognition and documented preferences for choosing clothes was repeatedly observed wearing a hospital gown while eating and moving about the facility, despite stating a preference for regular clothing and having only one change of clothes. Another resident with multiple chronic conditions was repeatedly observed in the same soiled shirt and pants with dried food and liquid, and stated there were no other clothes available. Staff interviews confirmed the residents lacked appropriate clothing options during the survey observations.
A cognitively intact resident with multiple chronic conditions, including COPD and chronic myeloid leukemia, was care planned to be encouraged to use the toilet for bowel evacuation, but staff followed Kardex instructions to use a bedpan and at times only placed incontinence pads under her instead. The resident reported to police that she had been left sitting in her bowel movement for several hours and that staff used chucks instead of a bedpan, causing discomfort and embarrassment. In interviews, she stated she preferred to be transferred with a lift to the toilet and had recently tolerated a sit-to-stand lift well. An LPN acknowledged miscommunication between shifts that led to the resident not receiving needed care and stated that residents required more attention than staff could provide, demonstrating a failure to provide dignified, care-planned toileting consistent with the resident’s preferences.
The facility failed to ensure resident dignity and self‑determination when a video camera with audio capability, installed by a resident’s POA in a shared room, remained in use without documented consent from either resident or their representatives. A cognitively impaired resident and that resident’s guardian were not properly informed of the camera’s presence, and the guardian later reported being unaware and uncomfortable with it. Record review showed no signed consent for the camera from the roommate’s POA and no documentation of any discussion at a care conference, and neither resident’s care plan addressed the ongoing audio/visual surveillance in the room.
Dignity During Transfer: A resident with legal blindness, moderate cognitive impairment, and mobility limitations was transferred from the restroom to her room on a stand-to-sit device while her pants were around her ankles and she was exposed in only a brief. CNA confirmed the transfer occurred that way, and the DON stated residents should be fully dressed in common areas and that the situation was a dignity issue.
A resident with dementia and age-related osteoporosis, who had severe cognitive impairment, was observed receiving personal care from a CNA while undressed, with the room door and privacy curtains left open, making the resident visible from the hallway. The CNA later admitted not providing privacy and dignity, and both the RN supervisor and DON stated that staff are expected to ensure privacy and appropriate coverage during care. Facility admission documents state that residents are to be afforded dignity, respect, and privacy in treatment and care for personal needs.
Catheter Bag Left Exposed: A resident with an indwelling Foley catheter and intact cognition was observed with an uncovered drainage bag attached to the calf, with urine visible in the bag and the bag visible from the hallway. The resident stated the exposed bag and urine bothered her and wished it could be covered; CNA and RN confirmed there was no privacy cover, and the DON stated the bag should have been covered to respect dignity.
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