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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 10, 2025
Corrected date: March 19, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey from 5/9/2024 to 5/16/2024, the facility did not ensure each resident was treated with respect and dignity in an environment that promotes maintenance of their quality of life for 2 of 3 residents (Resident #33 and #105) reviewed for dignity. Specifically, 1, Resident #33 was observed on several occasions wearing socks with name labels that were visible on the outside of both socks, and 2, Resident #105 was noted with photographs depicting the resident in positioning devices on the wall above the head of the bed and visible from the door. The findings are: Policy and Procedure reviewed 4/18/2024 documented all residents have a right to a dignified existence including the right to privacy and confidentiality. 1. Resident #33 was admitted with [DIAGNOSES REDACTED]. The 4/2/24 Quarterly Minimum Data Set documented Resident #33 was rarely/never understood, used a wheelchair, was dependent for upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During observation on 5/10/24 at 11:11 AM, 5/10/24 at 12:45 PM and 5/13/24 at 12:20 PM, Resident #33 was observed in the unit dayroom with pink socks on both feet. Name labels (resident name) were clearly visible on the outside of both socks. During an interview on 5/13/24 at 12:54 PM Staff #8 (Licensed Practical Nurse) stated it was policy that clothing items required name labels, if the facility did the residents laundry. Staff #8 stated that name label/s should be on the inside of socks, to avoid the name being visible to others. Staff #8 stated the visible name labels were a privacy and dignity issue. During an interview on 5/13/24 at 1:05 PM Staff #6 (Certified Nurse Aide) stated Resident #33's socks were labeled on the outside by the laundry staff. Staff # 6 stated that because Resident #33 did not wear shoes, the name labels on the socks were visible. Staff #6 stated they never reported to nursing that the name labels were visible on the outside of Resident #33's socks. During an interview on 5/13/24 at 1:30 PM Staff #7 (Licensed Practical Nurse Charge Nurse) stated that socks were labeled on the outside because most residents wore foot coverings/shoes. Staff #7 stated Resident #33 did not wear shoes. Staff #7 stated they were not aware that Resident #33's socks were labeled on the outside. Staff #7 stated they saw the concern as this was a dignity issue. 2. Resident #105 was admitted with [DIAGNOSES REDACTED]. The 3/31/24 Minimum Data Set documented Resident #105 had impaired cognition, and was dependent for all activities of daily living. During observation on 05/09/24 at 10:24 AM, 05/13/24 at 12:19 PM, and 05/14/24 at 10:09 AM, there were 2 photographs taped to the wall above Resident #105's bed. The photographs depicted the resident both in the wheelchair and in bed with a positioning device in place. The photographs were visible from the door and could be viewed by the resident's roommate and visitors. During an interview on 05/14/24 at 11:14 AM, Staff #23 (Physical Therapist) stated they posted the photographs behind the bed so the certified nurse aide understood the positioning device and how it should be placed. During an interview on 05/14/24 at 11:25 AM, the Director of Rehabilitation stated the photographs with the positioning devices should have been placed on the inside of the closet door, and should not be on the wall behind the bed. During an interview on 05/14/24 at 11:27 AM Staff #24 (Registered Nurse) stated the certified nurse aides used the photographs on the wall above the bed depicting the positioning device to show them how to use the positioning device. Staff #24 stated it was also on the care guide. 10NYCRR: 415. 3 (d)(1)(i) | Plan of Correction: ApprovedMarch 7, 2025 What corrective actions were taken for the affected resident: 1. Resident #1 suffered no ill effect from receiving pizza from another resident. Resident #1 was assessed by the Nurse Practitioner and chest radiograph was negative for aspiration pneumonia. Care plan was reviewed and revised. How will you identify others at risk to be affected by the alleged deficient practice: 1. A review on 2/12/2025 of current diet orders reveals no other residents have order for Nothing By Mouth. 2. Diet orders will be reviewed on all new admissions to identify residents with Nothing By Mouth status placing them at risk to be affected. Those at risk will be care planned appropriately. What measures will be put in place or what systemic changes you will make to ensure that the alleged deficient practice does not recur: 1. All staff were educated on Special Considerations for the Resident who is Nothing By Mouth.??ÿ 2. The facility will continue to educate all staff on Special Considerations for the Resident who is Nothing By Mouth.??ÿ on hire and annually. How the corrective action(s) will be monitored to ensure the deficient practice will not recur: 1. Nursing staff will conduct weekly audits of activities and/or dining to ensure residents with NPO orders are not present while food is being served. Audits will be conducted on various shifts weekly for four (4) weeks then monthly for two (2) months. Audit results will be forwarded to the Quality Assurance Process Improvement Committee for review and further recommendation. Responsibility: Director of Nursing or Designee |