Dignity Concern in Resident Dining Experience
Summary
The facility failed to provide a dignified dining experience for a resident, identified as Resident #7, who was observed eating lunch in a high-traffic hallway while seated in a wheelchair. Two staff members were seen adjusting the resident in his chair, with one assisting him with his meal while standing over him. The resident's admission record indicated a need for assistance with personal care, and interviews with staff revealed that the resident was placed in the hallway for monitoring during meals. The Director of Nursing acknowledged that seating the resident in the hallway could be a dignity concern, and it was noted that the facility lacked a policy related to dignified dining.
Plan Of Correction
1. Resident #7's plan of care has been updated to reflect the dining preferences of the resident/resident representative. The residents representative has received information specific to dignified dining, who verbalized understanding. 2. Director of Nursing/Designee has completed observation of current facility residents while dining to verify dignity is maintained. Follow up based on findings. 3. Staff Development Coordinator/Designee has completed education for current facility employees related to maintaining resident dignity while dining. 4. Director of Nursing/Assistant Director of Nursing/Unit Manager/Designee to complete random observations of residents while dining to ensure dignity is maintained. Observations will contain 10 residents/week x 3 months, then as needed until substantial compliance is achieved. Findings to be reviewed during the monthly Quality Assurance and Performance Improvement Committee Meeting. Modifications implemented as indicated.
Penalty
The facility failed to treat residents with dignity and provide timely care, as evidenced by multiple complaints. A resident felt uncomfortable with staff speaking foreign languages during care, while another described staff as rough and disrespectful. A resident's wife reported aides refusing to shave her husband properly. Other residents experienced delays in receiving assistance, rude behavior, and inadequate care, including a lack of hot water. The DON was informed of these issues during interviews.
The facility failed to maintain resident dignity and privacy, as evidenced by undignified language, lack of eating assistance, and exposure during personal care. Two residents were left without proper meal assistance, and another was referred to as a "feeder." Privacy was compromised for several residents, with open doors and inadequate coverage during care. Additionally, a resident experienced a delay in receiving their meal, highlighting a failure to adhere to dignity policies.
A facility failed to protect resident privacy when a staff member posted unauthorized videos of residents on social media. The videos, featuring residents from the secure memory care unit, were shared without consent, violating their dignity and privacy. Many residents were unable to provide informed consent due to cognitive impairments, and the facility's social media policy was not followed.
A resident was observed lying on her bed without underwear or a blanket, with the door open, on two occasions. The resident was fully dependent on assistance for mobility. A CNA acknowledged the importance of maintaining residents' dignity and privacy, stating that doors should be closed when providing care and that residents should always wear underwear.
Failure to Ensure Dignity and Timely Care for Residents
Penalty
Summary
The facility failed to ensure residents were treated with dignity during activities of daily living (ADLs) care and failed to provide care upon request for several residents. Resident #254 reported feeling uncomfortable when staff spoke in foreign languages during care, which she did not understand. Resident #251 described the staff as rough, pushy, and disrespectful, noting that they did not greet him or work well together. Resident #256's wife expressed concerns about the refusal of aides to shave him, despite her providing a razor, and noted that the aides did not perform the task well. Resident #55 found it rude when staff did not speak English while providing care, and Resident #83 reported that staff had a nasty attitude and argued while caring for her. Resident #250 experienced delays in receiving assistance for a diaper change, with aides showing an attitude and not responding promptly to her requests. She also mentioned filing a complaint without receiving a resolution. Resident #23 reported inadequate care, including an incident where a CNA poured cold water on her, causing her to stop breathing momentarily. The surveyor confirmed the lack of hot water in her bathroom. The Director of Nursing was informed of these concerns during interviews, where the issues raised by residents and their families were discussed. The report highlights multiple instances where the facility did not meet the required standards for treating residents with dignity and providing timely care, as evidenced by the residents' testimonies and the surveyor's observations.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 residents #254, 251, 256, 55, 83, and 23 were assessed by licensed nurse, no concerns identified related to alleged deficient practice. Resident #251 discharged on 4.9.25 and is no longer residing in the facility. Resident #256 discharged on 4.8.25 and is no longer residing in the facility. Resident #250 discharged on 4.2.25 and is no longer residing in the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.11.25 the Director of Social Services completed a quality review of current residents to ensure that residents' rights are honored with emphasis treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights. Any concerns identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.17.25, an Ad Hoc Resident council meeting was held to review survey results and plans being implemented for correction of alleged deficient deficiencies. On 4.22.25, the Director of Nursing completed education with current staff on the components of N203 Resident Rights with an emphasis on treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights by the Assistant Director of Nursing/designee. Newly hired staff will be educated on the components of N203 Resident Rights with an emphasis on treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights by the Assistant Director of Nursing/designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 residents 2 times a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with N203 residents' rights are honored with emphasis on treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to provide eating assistance in a dignified manner for two residents observed for in-room dining. One resident was left unattended with a food tray for approximately 25 minutes without staff assistance, despite needing supervision and assistance during meals. Another resident was referred to as a "feeder" by staff, which is considered undignified language. Additionally, a resident's privacy was compromised as they were left without a privacy pouch for their drainage bag, contrary to their care plan requirements. The facility also failed to maintain privacy during personal care for several residents. One resident was observed with their room door open and privacy curtain partially drawn while receiving care, exposing them to the hallway. Another resident was found with their bed covers off, exposing their disposable brief and tubing, with the room door open, allowing full view from the hallway. These observations indicate a lack of adherence to the facility's dignity policy, which emphasizes maintaining privacy and respectful communication. Furthermore, a resident experienced a delay in receiving their lunch tray, resulting in them waiting 19 minutes after their roommate had already finished eating. This delay in meal service is inconsistent with the facility's policy of treating residents with dignity and ensuring timely assistance. The report highlights multiple instances where the facility's actions or inactions failed to uphold the residents' right to be treated with dignity and respect, as required by the facility's policies and procedures.
Plan Of Correction
N203 RIGHT TO BE TREATED WITH DIGNITY 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #82, being referred to as a "feeder". Staff will be in-serviced regarding dignity, not calling residents "feeders" but as someone who needs assistance with feeding. 2) In the allegation of Resident #103, waiting a long time to be fed. Staff will be in-serviced not to leave trays in the room, but to feed residents in a timely manner as to not cause dignity issues. 3) In the allegation of Resident #103, not having a privacy pouch for bags. Nursing staff will be in-serviced to ensure residents with bags have privacy covers for them. 4) In the allegation of Resident #175, privacy during care. Nursing staff will be in-serviced to provide privacy for residents while they are receiving care. 5) In the allegation of Resident #275, delay in feeding, residents in the same room should be brought their trays at the same time. Staff will be in-serviced to bring food trays to all residents in the same room at the same time not to cause dignity issues. 6) In the allegation of Resident #475, door open no covers (linens) covering resident, resident exposed in only a brief and a shirt. Nursing staff will be in-serviced to ensure residents are dressed or covered for privacy and dignity. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - In-service staff about dignity, not calling residents "feeders" but as someone who needs assistance with feeding. - In-service staff not to leave trays in room, to feed residents in a timely manner as to not cause a dignity issue. - In-service Nursing staff to ensure residents with bags have privacy covers for them. - In-service nursing staff to provide privacy for residents while they are receiving care. - In-service staff to bring food trays to all residents in the same room at the same time not to cause a dignity issue. - In-service nursing staff to ensure residents are dressed or covered for privacy and dignity. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date:
Unauthorized Social Media Posts Violate Resident Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by unauthorized videos of residents being posted on social media platforms. These videos, which included residents dancing or appearing in the background, were recorded by a staff member, the Admissions Coordinator, without obtaining consent from the residents or their legal representatives. The videos were shared widely, garnering significant views and interactions online, which violated the residents' rights to privacy and confidentiality. The report highlights that 10 out of 16 sampled residents were affected by this breach of privacy. Many of these residents resided in the secure memory care unit and had diagnoses that impaired their ability to provide informed consent. For instance, Resident #10, who was featured in the videos, had been diagnosed with conditions affecting her cognitive abilities, and her admission record indicated she was unable to make willful and knowing health decisions. Similarly, Resident #14's Health Care Surrogate confirmed that no consent was given for the social media postings, and Resident #13's records showed she was incapable of communicating health decisions. Interviews with facility staff, including the Nursing Home Administrator and the Regional Nurse Consultant, revealed that the videos were discovered inadvertently through social media. The staff involved did not inform the administration about the recordings, and it was only after the videos were identified online that the issue was addressed. The facility's policy on social media use explicitly prohibits unauthorized recordings and postings, yet this policy was not adhered to, leading to the violation of residents' rights.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Facility contacted residents responsible parties/representatives/families of residents #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16 to notify them that the residents were posted on social media by a staff member, without the facility's knowledge. Staff members were advised to remove all resident-related content from social media. All videos found were reported to the social media to remove videos. The legal department at Tik Tok was contacted to remove videos. Staff member was terminated. 2. Identification of other residents having the potential to be affected: Multiple social media platforms reviewed to identify any postings of facility residents. Facility-wide audit of all residents currently residing in the facility to verify photo consents are signed and present in the medical record. The photo consent form. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to treat a resident with dignity and provide personal privacy, as observed during the survey process. The resident, who was admitted with multiple diagnoses and was fully dependent on assistance for mobility, was seen lying on her bed without underwear or a blanket, with the door open, on two separate occasions. During an interview, a Certified Nurse Assistant (CNA) acknowledged the importance of maintaining residents' dignity and privacy, stating that doors should be closed when providing care and that residents should always wear underwear, especially if they are not fully clothed.
Plan Of Correction
Boca Circle Rehabilitation Center failed to treat the resident in a dignified manner and provide personal privacy. **Actions Taken:** 1) On resident #108 was provided with personal privacy during personal care by the C.N.A. Education was initiated on with staff regarding providing dignity and privacy for residents during personal cares. **Others Identified:** 2) Full house audit was conducted by the DON/Designee on to ensure privacy was being provided during personal care. No other concerns were noted. **Measures Taken:** 3) Nursing Staff were re-educated on regarding regarding resident rights, dignity and privacy during personal cares and that privacy curtains must be pulled and the door closed so residents are treated in a dignified manner. New staff will receive this education during general orientation. **Ongoing Monitoring:** 4) Unit Manager or designee will audit personal care and resident right to privacy during personal cares weekly x 4 weeks, and then every 2 weeks x 2 months. Audit results will be reviewed in Center QAPI meeting monthly until substantial compliance has been met.
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