A nurse administered meds to a resident while the resident was seated on the toilet in the lavatory, rather than waiting until the resident was in a more appropriate setting. The resident had dementia with a BIMS score of 0, and the care plan did not address med administration in the lavatory. The DON stated this was not appropriate, and the facility’s dignity policy prohibited demeaning practices and required staff to treat cognitively impaired residents with dignity and sensitivity.
A resident with bipolar disorder, chronic pain syndrome, edema, neuralgia, and neuritis, and with a BIMS of 15/15, was observed being transported backwards in a recliner chair from the hallway to the lounge area. The CNA acknowledged residents should be moved forward facing, and the LPN/UM, DON, and LNHA all stated that pulling a resident backwards was not appropriate and was a dignity issue.
A cognitively intact resident with a left shoulder fracture told an RN that they did not want any male caregivers, and the RN assured the resident this preference would be honored. However, the preference was not documented in the medical record, not added to the care plan, and not communicated in shift-to-shift reports. As a result, a male CNA provided care to the resident, and leadership later confirmed they were unaware of the preference and that the failure to follow it occurred at the nursing level, despite facility policy allowing residents to choose healthcare providers consistent with their interests and personal care needs.
Facility staff restricted cognitively intact residents' access to outdoor areas and limited smoking opportunities, allowing only three supervised smoke breaks per day with a maximum of two cigarettes per session. Both smokers and non-smokers were unable to access the patio at their leisure, and staff cited safety concerns as the reason for these restrictions. Residents expressed dissatisfaction with the lack of individualized consideration for their preferences and the inability to go outside or smoke according to their own routines.
A resident with severe cognitive impairment was video recorded without consent by a Housekeeping Aide at an ENT doctor's office. The resident appeared upset and confused, believing they had been kidnapped. The transport driver continued recording after taking the aide's phone. ENT staff witnessed the aide yelling and belittling the resident. The DON confirmed staff were trained not to record residents, indicating a breach of the resident's rights to dignity and privacy.
A facility failed to ensure a resident's privacy and dignity during medication administration. An LPN administered medications and checked a resident's blood pressure in the dining area, contrary to the facility's Resident Rights Policy. The resident's preference for this setting was not documented in their care plan, leading to a deficiency.
A resident with dementia and muscle weakness was transported backwards in a geriatric chair by a CNA, which was observed by a surveyor. The facility lacked a specific policy on transport direction, although staff interviews indicated that transporting residents backwards is not standard practice and should be avoided for safety and comfort reasons.
The facility failed to provide a dignified dining experience for residents by serving beverages in disposable plastic cups, as observed in one dining room. The LNHA and DON did not refute this concern, and the facility's meal assistance policy did not address the use of non-disposable dinnerware, leading to a deficiency in promoting dignity and respect.
Two residents were not served meals in a dignified manner, with one resident left unattended and not fed promptly, and another not receiving their requested meal items. Staff fed residents while standing, contrary to facility policy, and communication issues led to incomplete meal service.
A resident with severe cognitive impairment and multiple medical conditions was observed in the dining room with their back exposed due to an untied hospital gown. Nursing staff provided the meal tray without ensuring the resident was properly covered, resulting in a failure to maintain the resident's dignity as required by facility policy.
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