Failure to Provide Dignified Care and Timely Response to Resident Needs
Penalty
Summary
The facility failed to provide care in a dignified manner for two residents who were cognitively intact and had specific care needs. One resident, with a history of congestive heart failure and muscle weakness, was observed to have repeated delays in response to call lights, with documented wait times ranging from 29 to 57 minutes on multiple occasions. The resident reported frequent long waits for assistance, particularly when needing to be changed due to a wet brief, leading to discomfort and embarrassment. Staff interviews revealed that call light notifications were only accessible via electronic tablets or a monitor at the nursing station, and not all staff consistently carried the required tablets, further contributing to delayed responses. Another resident, diagnosed with muscle weakness and chronic obstructive pulmonary disease, reported that staff often used their personal cell phones to text while providing care in the resident's room. The resident expressed feeling ignored and that staff attention was diverted away from her needs during care interactions. The facility had a policy prohibiting the use of personal cell phones in resident care areas, but the resident's account and staff behavior indicated this policy was not consistently followed. These deficiencies were identified through direct observation, resident interviews, staff interviews, and review of facility records and policies. The events described demonstrate a lack of respect for resident dignity and failure to maintain an environment that promotes quality of life, as required by federal regulations. The issues included both delayed response to resident needs and inappropriate staff conduct during care provision.
Plan Of Correction
F550 1. Residents #401 and #10 still currently reside in the facility. The cited residents did not sustain harm from the deficient practice and are at their psychosocial baseline. Their call lights have been evaluated and are working appropriately. 2. Current residents have the potential to be affected by this deficient practice; a sweep was completed on both units to assess the working order of every resident's call light on 6/6/2025. Residents were interviewed regarding observing staff on cell phones in resident rooms on 6/6/2025. Any resident with a concern had a resident concern form filled out on their behalf. 3. Policies on call lights and use of personal cell phones were reviewed and deemed appropriate. Clinical staff have been educated on these policies by 6/6/2025 by the DON/designee. Facility charge nurses were provided with call light receivers to ensure proper notification of call lights. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure call lights are answered timely and staff are not utilizing their personal cell phones in care areas. The Admin/designee will perform a 3x weekly audit on call light receivers to ensure receivers are functioning and audible. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.