Failure to Ensure Dignified Care, Timely Assistance, and Communication for Residents
Penalty
Summary
The facility failed to provide dignified care and timely assistance to two residents who required help with toileting and mobility. One resident, who was non-weight bearing on both lower extremities and required assistance for toileting, reported that staff did not respond promptly to call lights, sometimes turning them off without providing the needed help. This resident experienced episodes of incontinence and humiliation after being told by staff to defecate in bed due to the unavailability of a bed pan, despite being continent and able to make his own medical decisions. The resident began wearing briefs out of concern that staff would not respond in time to his needs. Another resident, also cognitively intact and able to make her own medical decisions, reported similar issues with delayed call light response and staff turning off the call light without returning to assist. As a result, this resident experienced incontinence and emotional distress. Both residents' experiences were corroborated by their own accounts and observations during the survey, and the facility's policy required call lights to be answered promptly and not turned off until the resident's needs were met. Additionally, the facility failed to ensure effective communication and self-determination for a Spanish-speaking resident who was dependent on staff for all transfers and toileting hygiene. The medical record indicated that this resident was her own decision maker, but there was no communication care plan in place to guide staff in engaging her in her care. Documentation showed that staff and medical providers did not consistently use translation services, resulting in the resident being unable to communicate her needs or participate in care decisions, including pain management and reporting incidents such as falls.