Failure to Provide Timely Assistance and Maintain Resident Dignity
Penalty
Summary
The facility failed to provide prompt assistance to meet the care needs of three residents, compromising their dignity and quality of life. Resident R67, who has coronary artery disease and heart failure, reported sitting in a soiled brief for over an hour, with delays in response to call lights being a regular occurrence. Resident R63, diagnosed with seizure disorder and bipolar disorder, experienced similar delays, having to wait over an hour for assistance after an accident in bed. This resident also expressed discomfort with being woken up at 2:00 a.m. to change briefs, which they found disruptive. Resident R8, who has heart failure and sepsis, was observed without pants, wearing only a shirt and a brief, which they expressed dissatisfaction with. The facility's failure to provide timely assistance and maintain an environment that promotes dignity was confirmed by the Nursing Home Administrator and the Director of Nursing. These incidents highlight a lack of adherence to the facility's policy on resident rights, which mandates treating residents with kindness, respect, and dignity.
Plan Of Correction
Immediate Intervention: Staff for residents identified R67, R63, and R8 were notified that residents' rights were violated in the stated manor. Immediate counseling on resident rights to CNAs was provided. R67 and R63 were provided with immediate hygiene care and R8 was given hygiene care and lower body dressing provided. Identification of other residents who potentially can be affected: All residents residing in the building could potentially be affected by this violation of resident rights. Prevention of future occurrence: Educate all nursing staff on the call light response policy. Corrective Action to be monitored: DON/designee will complete the following audits. Call light response time will be monitored using an audit tool. DON/designee will interview 3 residents of each unit to determine if resident's rights are being violated. Audits for call-bell response times and interviews will be completed: 5 times per week for three weeks. Weekly for three weeks and then monthly for three months. QA Program: Call light response and maintaining Residents' rights will be added to Monthly QAPI meeting review.