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.
Surveyors observed CNAs standing over two dependent residents during meals and one CNA feeding both residents interchangeably, rather than providing individualized, seated assistance as required by facility policy. One resident had severe cognitive and physical impairments, including spastic hemiplegia, paraplegia, aphasia, and moderate protein-calorie malnutrition, and required max assist with eating. The other had encephalopathy, CKD, type 2 DM, adult failure to thrive, Alzheimer’s, dementia, depression, and anxiety, and was totally dependent on staff for eating. Despite care plans and care cards specifying one-on-one assistance, staff stood while feeding and alternated bites between the two residents, and later explained they did not see available seats, while the DON confirmed staff are expected to sit when feeding residents.
A resident with Parkinson’s disease and impaired communication was observed without the prescribed jingle bell communication aid while out of the room. Staff later found the bell in the resident’s room, and the resident’s spouse reported the bell is not always kept with the resident even though it is supposed to be used when the resident is not in bed.
A resident with reduced mobility and muscle weakness, who was cognitively intact and care planned for assistance with toileting, activated a call light requesting help with a bedpan due to diarrhea and concern about soiling herself. Surveyors observed the call light on for 57 minutes before an ADON entered, asked what was needed, and provided assistance. During this period, multiple staff, including dietary and housekeeping personnel and a CNA responsible for the resident, entered or were aware of the situation but did not address the call light or provide the requested toileting assistance. This response time exceeded the facility’s stated expectation of responding to call lights within 15–20 minutes and did not follow the written call light procedure requiring timely response and completion of the resident’s request before turning off the call light.
A resident with progressive MS and intact cognition refused a new bed when the facility implemented a building-wide bed replacement, but staff and a corporate representative proceeded to replace the bed and mattress despite her objections. After the change, the resident repeatedly reported severe back and hip pain attributed to the new bed, and documentation showed a significant increase in pain scores and frequent PRN Norco use during this period. When staff later agreed to switch her back to an older bed, an ISW and housekeeping moved numerous personal items out of her room, and housekeeping unilaterally took some of these belongings to a garbage chute room without the resident’s consent, contrary to her care plan that directed staff not to remove items without her participation. The resident became visibly upset when she discovered missing items and reported that not all of her belongings, including a bag of snacks, were returned, demonstrating a failure to respect her dignity, self-determination, and property.
An RN failed to treat two residents with dignity and respect during care. One resident with intact cognition was given nebulizer-related care and lung assessment without the RN announcing herself or explaining the procedure, and the resident later said they did not know the assessment occurred. Another resident with severe cognitive impairment received insulin in the dining room without explanation, privacy, or permission, despite the DON stating residents should be taken out of the dining room unless they agree to receive the injection there.
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