Failure to Ensure Resident Dignity and Communication
Penalty
Summary
Surveyors found that the facility failed to honor residents' rights to a dignified existence and effective communication for three of four sampled residents. During a 45-minute observation on the second floor, no staff members were present at the nurses' station or visible on the unit, which housed 40 residents. Interviews revealed that one resident's spouse was unable to contact facility staff by phone and rarely saw nurses or CNAs during visits. Another resident's spouse reported minimal staff presence in the resident's room, difficulty obtaining assistance, and a lack of follow-up from the front desk. Additionally, a resident expressed frustration at being unable to reach social services by phone, despite repeated attempts and being transferred by the front desk without success. Record reviews indicated that the affected residents included individuals with mild cognitive impairment following a cerebrovascular accident, as well as residents with intact cognition, one of whom was admitted for aftercare following joint replacement surgery. The administrator acknowledged receiving frequent messages from residents and families and noted that the social worker was off on the day in question, but these explanations did not address the observed lack of staff presence and communication barriers experienced by residents and their representatives.