§483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.
§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.
§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.
§483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.
§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
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Observations:
Based on review of facility policy, review of clinical records, observations, and staff and resident interviews, it was determined that the facility failed to maintain resident dignity for two of five residents reviewed (Resident R2 and R4). Findings Include:
Review of facility policy "Resident Rights", effective November 2016, revealed the resident has a right to a dignified existence inside the facility. Further review of facility policy revealed the facility must treat each resident with respect and dignity, and care for each resident in a manner, and in an environment, that promotes maintenance, or enhancement, of quality of life, recognizing each resident's individuality.
Review of Resident R2's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 4, 2023, revealed the resident was cognitively intact and was dependent on staff for upper and lower body dressing.
Review of Resident R4's comprehensive MDS dated January 25, 2024, revealed the resident was cognitively intact and required partial/moderate assistance with upper body dressing.
Observations from the hallway on February 7, 2024, at 1:15 p.m. revealed Resident R2 was laying in the bed closest to the door. Resident R2 was observed to be dressed in a hospital gown with brief exposed. Interview with Resident R2 revealed the resident had personal clothing in the dresser.
Interview on February 7, 2024, at 1:20 p.m. with nurse aide, Employee E3, confirmed observations of Resident R2. Further interview with nurse aide, Employee E3, confirmed Resident R2 had personal clothing in the dresser and would assist the resident with getting dressed.
Observations from the hallway on February 7, 2024, at 1:35 p.m. revealed Resident R4 walking around the room in a hospital gown and brief exposed. Interview with Resident R4 revealed the resident had personal clothing in the closet and would prefer to be dressed in personal clothing.
Interview on February 7, 2024, at 1:40 p.m. with licensed nurse, Employee E4, confirmed observations of Resident R4 and confirmed the resident had personal clothing in the closet.
211.10 (d) Resident care policies.
| | Plan of Correction - To be completed: 04/07/2024
Residents R2 and R4 were reviewed and care planned for dressed preferences.
Staff has been educated on following residents' preferences and maintaining proper hygiene.
Unit Managers or designee will complete a random daily audit for 4 weeks to ensure residents' preferences and hygiene needs are met. Findings will be reviewed in QAPI.
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