Failure to Honor Resident's Right to Dignity and Self-Determination
Summary
A deficiency occurred when a Certified Nurse Assistant (CNA) entered the room of a resident who had previously requested not to receive care from that CNA, following a complaint from the resident's family member. Despite an agreement that the CNA would not be assigned to provide care to this resident, the CNA entered the resident's room to provide care to the roommate and closed the curtain for privacy. Staffing records confirmed that the CNA was assigned to the roommate, not the resident in question, but the Director of Nursing (DON) acknowledged that, due to the known conflict and complaints, the CNA should not have been assigned to the room at all. The resident involved had multiple medical conditions, including hemiplegia, hemiparesis, acute respiratory failure, diabetes mellitus, asthma, and post-traumatic stress disorder (PTSD). The resident's cognitive skills were moderately impaired, and they were dependent on staff for all activities of daily living. The facility's policy stated that residents have the right to be treated with respect, kindness, and dignity, and to participate in decision-making regarding their care. The failure to honor the resident's request and the facility's own policy resulted in a violation of the resident's rights.
Plan Of Correction
F550 Resident Rights/Exercise of Rights 1. How corrective actions will be accomplished for those residents found to have been affected by the deficient practice. • Resident 1 remains in the facility and has no complaints/issues about his CNA. • CNA 1 will no longer be assigned to resident '1's roommate and cannot enter room since 08/02/2025. • Resident 1's care plans were reviewed and updated according to his needs. • The DON provided in-service education regarding Resident Rights Policy and Procedures to nursing, rehab, activity, respiratory, and department heads' staff on 08/14/2025, 08/15/2025, 08/18/2025, 08/19/2025, and 08/20/2025. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective actions will be taken. • The Administrator, DON, and Social Services Director (SSD) randomly interviewed alert and oriented residents to address any concerns/issues regarding their CNA, ensuring they are treated with respect, kindness, and dignity, and participate in decision-making regarding their care; no concerns/issues were brought up. • There were no other residents affected by this deficient practice. • The DON provided in-service education regarding Resident Rights Policy and Procedures to nursing, rehab, activity, respiratory, and department heads' staff on 08/14/2025, 08/15/2025, 08/18/2025, 08/19/2025, and 08/20/2025. 3. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not occur. Systemic changes will be achieved through in-service education and corrective action monitoring utilizing the facility quality assurance process. • The DON provided in-service education regarding Resident Rights Policy and Procedures to nursing, rehab, activity, respiratory, and department heads' staff on 08/14/2025, 08/15/2025, 08/18/2025, 08/19/2025, and 08/20/2025. • The RN supervisor and charge nurse will review the assignment sheet every shift to ensure that staff who have issues with the resident will not be assigned to the resident's room and cannot enter the room. Any findings will be corrected immediately and reported to the DSD and DON for follow-up and corrections for future pre-assigned assignment sheets. • The RN supervisor will randomly observe staff daily when providing care to the residents to ensure residents are treated with respect, kindness, and dignity, and that staff comply with resident care plans. Any findings will be corrected immediately and reported to the DON for follow-up and corrective actions. • Department Heads will conduct daily room rounds and interview the residents regarding any concerns/issues regarding their CNA, ensuring they are treated with respect, kindness, and dignity, and participate in decision-making regarding their care. Immediate correction will be carried out upon notice of issues/concerns. Any findings during their room rounds will be discussed in the stand-up meeting for corrective actions and follow-up. • The DSD or designee will continue to provide in-service education regarding Resident Rights. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator and/or DON shall implement, monitor, and evaluate this Plan of Correction. The SSD or designee will recapitulate findings related to Resident Rights issues at the monthly QAA meeting for further evaluation, recommendation, and/or appropriate improvement actions. If it is determined that we have accomplished the objectives in the Plan of Corrections above and the results are successful, then the facility will consider the matter resolved. The QAA Committee will continue to review until the deficiency has been proven resolved for two consecutive months and/or advised by the QAA Committee.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to Knock Before Entering Rooms and Exposed Urinary Bag: A CNA entered three residents' rooms without knocking, and each resident said staff should knock and that they preferred privacy. The residents had diagnoses including encephalopathy, heart failure, respiratory failure, malnutrition, and sepsis, with moderate cognitive impairment documented for three of them. In addition, a resident with a urinary catheter was observed with an exposed urine bag hanging from the bed without a privacy cover, and the urine could be seen from the hallway; interviews confirmed privacy covers were required and that exposed urine affected dignity.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's dignity was not maintained during a blood sugar check when an RN performed the finger stick in the day room with two other residents and a visitor present and loudly announced the result. The RN did not ask permission before checking the resident's blood sugar in the common area, and the resident was described as alert, oriented, and new to the facility.
Cell Phone Use During Resident Care: CNAs were observed and reported using personal cell phones while providing care, including showers, in resident rooms, at nurses’ stations, in hallways, and while supervising smoking times. Nine confidential residents said the behavior made them feel ignored, embarrassed, and that their privacy was violated. The DON and ADM stated residents should receive privacy and full attention during care, and the facility policy required staff to treat residents with kindness, respect, dignity, privacy, and confidentiality.
Staff failed to maintain resident dignity during wheelchair transport and assisted feeding. A resident with dementia and severe cognitive impairment was transported in a geriatric wheelchair while facing backward, slumped over, and moaning as a CNA pulled the chair from the front, preventing the resident from seeing where he was going. Two cognitively impaired, fully dependent residents were assisted with eating by CNAs who stood over them rather than sitting at eye level, despite chairs being available in the room and dining area. One CNA reported not knowing she was expected to sit while feeding, and another stated she remained standing to monitor other residents who were self-feeding while she was the only staff member present.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Knock Before Entering Rooms and Exposed Urinary Bag
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity when CNA B did not knock before entering the rooms of Resident #20, Resident #59, and Resident #64. Resident #20 was a female with diagnoses including metabolic encephalopathy, hypertensive chronic kidney disease, hyperlipidemia, hypertension, weakness, and unsteadiness on feet, and her BIMS score was 08. Resident #59 was a female with diagnoses including heart failure, respiratory failure, muscle weakness, GERD without esophagitis, hypertension, and sepsis, and her BIMS score was 10. Resident #64 was a male with diagnoses including protein-calorie malnutrition, sepsis, hypertension, kidney failure, and alcohol abuse, and his BIMS score was 09. Each resident stated staff did not knock on the door and that they wanted staff to knock before entering their rooms. Observations during breakfast tray pass showed CNA B entering Resident #59's room at 7:17 a.m., Resident #64's room at 7:25 a.m., and Resident #20's room at 7:28 a.m. without knocking first. During interviews, Resident #59 said staff were supposed to knock and that staff would just walk in, including when she was being changed. Resident #64 said staff walked into his room all the time and that he got irritated when they did not knock. Resident #20 said staff never knocked on the door and that she preferred they knock, especially if the door was closed. The facility also failed to ensure Resident #102's urinary catheter had a privacy cover. Resident #102 was a female with diagnoses including hearing loss, pain, hypertension, cognitive communication deficit, and a rib fracture with pain, and her BIMS score was 99, indicating unable to complete the interview. Observations showed a urinary bag hanging from the side and bottom of her bed with no privacy cover, and the urine was visible from the hallway. Interviews with CNA B, MA F, CNA A, Central Supply, and the DON indicated privacy bags were supposed to be used for urinary bags and that exposed urine affected dignity and self-worth. The resident's care plan did not reflect anything about the catheter, and the report states the Dignity Policy required each resident to be cared for in a manner that promotes and enhances well-being, satisfaction with life, and feelings of self-worth and self-esteem.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Maintain Resident Dignity During Blood Sugar Check
Penalty
Summary
The facility failed to maintain a resident's dignity during a blood sugar check for Resident 97. During an observation on 5/1/26 at 11:21 a.m., RN 1 prepared to check the resident's blood sugar while the resident was sitting in her wheelchair in the day room with two other residents and a visitor present. RN 1 told the resident she was going to check her blood sugar, stuck the resident's finger, checked the blood sugar, and announced the result loudly in the common area. RN 1 did not ask the resident for permission to perform the blood sugar check in the common area with others present. During an interview later that day, Unit Manager 1 stated the resident was alert and oriented and new to the facility, and that they were working on a care plan indicating the resident was okay with having her blood sugar checked in common areas.
Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and care in a manner that promotes quality of life and recognizes each resident’s individuality for 9 confidential residents. The deficiency was based on resident interviews and record review showing that CNAs were using personal cell phones while providing care, including assisting with showers, performing care in resident rooms, and supervising residents during supervised smoking times. Residents stated staff texted and talked on their phones while walking in hallways, at nurses’ stations, and while performing care in their rooms, and they reported that this occurred on every shift and often in the facility. The residents also stated they did not know the names of the CNAs involved. The 9 confidential residents stated the cell phone use made them feel ignored, not a priority, embarrassed, and concerned that a CNA could make a mistake because of distraction. They also stated their privacy was violated. During interviews, the DON and ADM stated residents should receive privacy and full attention during care, and both stated staff were trained on privacy, resident rights, dignity, and cell phone usage. The record review included the facility policy titled Resident Rights, dated February 2021, which stated employees shall treat all residents with kindness, respect, and dignity and that residents have the right to a dignified existence, to be treated with respect, kindness, and dignity, and to privacy and confidentiality.
Failure to Maintain Resident Dignity During Transport and Assisted Feeding
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity and respectful treatment during transport and meals. One resident with dementia, anxiety, severe cognitive impairment, and total dependence for ADLs was observed seated in a geriatric wheelchair, slumped over with his head hanging and eyes open, and moaning while a nurse aide pulled the chair down the hall from the front, causing the resident to face backward and be unable to see where he was going. The aide reported she pulled the chair because it was hard to push and acknowledged she had been educated on dignity and respect and should have pushed the resident in front of her, which would have allowed her to see his slumped posture and hear his moaning. The DON confirmed that the resident should have been pushed in front of the aide and that this was a dignity issue. The deficiency also includes failure to promote dignity during meals for two residents with severely impaired cognition who were dependent on staff for eating. One resident with a traumatic brain injury was observed in bed with the head of the bed elevated while an agency nurse aide stood over the bedside and assisted with eating without sitting at eye level, despite a chair being available in the room; the aide stated she had never heard of needing to sit to feed a resident and only sat after being questioned. The other cognitively impaired, fully dependent resident in a semi-reclined geriatric chair in the dining room was fed by the same nurse aide, who stood over the resident while feeding despite an empty chair being available; the aide later stated she believed she had no chair and also needed to stand to watch three other residents feeding themselves at another table while she was the only staff member present in the dining area. The DON stated she expected staff to sit when assisting residents during meals to promote dignity.
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