Resident Left Overnight on Hallway-Visible Couch in Soaked Brief, Violating Dignity and Privacy
Summary
The deficiency involves the facility’s failure to ensure a resident’s dignity, privacy, and basic care needs were maintained during an overnight shift. The resident was an elderly female with severe cognitive impairment (BIMS score of 5), dementia with behavioral disturbance, cognitive communication deficit, muscle weakness, difficulty walking, insomnia, unsteadiness, and urinary frequency. Her care plan and MDS documented that she used a wheelchair, was dependent for toileting and transfers, required substantial/maximal assistance, and was to receive toileting assistance every two hours and as needed, with incontinent care after each episode. She was also on hospice with interventions to keep her clean and comfortable, and to maintain her dignity by being kept clean and dry. Active orders included brief checks every three hours and assistance of one to two staff for bed mobility and transfers. On the night in question, an LVN assigned to another hall (LVN C) was called to assist an agency LVN (LVN D) working her first shift in the facility on the 400 hall. When LVN C entered the suite shared by the resident and another resident, she observed the resident asleep on a couch in the entryway, visible from the hallway, wearing only a t‑shirt and a soaked brief. LVN C told LVN D that the situation was not acceptable, but LVN D responded that the resident would sleep wherever she wanted and stated she did not have time to “baby talk” residents. LVN C then returned to her own hall and called the on‑call ADON to report concerns about the residents on the 400 hall, including this resident lying on the couch in a soaked brief and t‑shirt. Camera footage later reviewed by the administrator showed that LVN D did not enter any resident room on that hall until after 10:00 PM and, throughout the night, did not remain in any room for more than two minutes, except for a three‑minute period around 4:30 AM when she and LVN C entered the suite of this resident and another resident. When day shift staff arrived the following morning, RN F and LVN H, after being alerted by LVN C, found the resident still asleep on the couch in the entryway to her suite, in view of the hallway, wearing only a t‑shirt, with a soaked brief on the floor next to the couch and urine soaking the couch around her. LVN H noted the resident’s wheelchair was next to her and that the resident’s bed was unmade. The resident later did not recall sleeping on the sofa. Multiple staff members, including LVNs, CNAs, the social worker, dietary staff, ADONs, the DON, and the administrator, stated in interviews that leaving a resident in a wet or soiled brief, or sleeping overnight on a couch in view of the hallway in only a t‑shirt and brief or just a t‑shirt, was not acceptable, was considered neglect, and negatively affected dignity, privacy, and basic care expectations. Facility documents, including the admission packet and the Patient/Resident Rights policy, stated that residents have the right to a dignified existence, privacy, and to be treated with respect and dignity, and that the facility must protect and promote these rights and provide care in a manner that maintains or enhances quality of life. The resident’s care plan and orders required regular toileting assistance, incontinent care after each episode, monitoring of appearance, and measures to keep her clean, dry, and comfortable, including checks of her brief every three hours. Despite these documented needs and interventions, the resident was left overnight on a couch in a public‑view area, inadequately clothed and in a soaked brief that was ultimately removed and left on the floor, with urine saturating the couch. The agency LVN assigned to her hall reported being alone without CNA support and unable to perform transfers due to a back injury, and stated that the resident had refused care and insisted the couch was her bed. However, the video evidence and staff interviews showed that the LVN provided minimal in‑room care throughout the night and did not ensure the resident was toileted, cleaned, appropriately dressed, or placed in bed or otherwise covered in a private setting. This sequence of inactions and observations led to the determination that the facility failed to treat the resident with respect and dignity and to provide care in an environment that maintained or enhanced her quality of life, as required by resident rights and facility policy. Staff interviews consistently characterized leaving a resident in unchanged, wet briefs and exposed in a public‑view area as neglectful and as a violation of dignity and privacy. The DON, ADONs, and other staff stated that any staff member who observed such a situation was responsible for intervening, including waking the resident, returning her to bed, dressing and covering her, or at minimum providing a blanket and pillow and ensuring she was not visible from the hallway. The facility’s own resident rights documents emphasized the right to safe, decent, and clean conditions, courtesy, consideration, respect, and privacy in personal care and accommodations. The events of that night, as documented by staff accounts, video footage, and the resident’s condition when found by day shift, demonstrated that these standards were not upheld for this resident.
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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