Failure to Provide Timely ADL Assistance and Call Light Response, Compromising Resident Dignity
Penalty
Summary
The facility failed to ensure timely assistance with activities of daily living (ADLs), specifically toileting, and did not respond promptly to call lights, compromising the dignity of several residents. One resident with severe cognitive impairment and frequent incontinence was observed repeatedly requesting help to use the bathroom over a 35-minute period, both verbally and by seeking out staff, but did not receive assistance. During this time, staff members, including CNAs and a patient aid, informed the resident that they could not help due to being occupied with feeding other residents, and the resident ultimately experienced an episode of incontinence in a public area, becoming visibly upset and distressed. Other residents also reported excessive wait times for call lights to be answered, with some stating they had to attempt self-toileting to avoid accidents, despite requiring assistance. Multiple residents described call light response times as too long, sometimes up to an hour, particularly during meal times or when staffing was reduced. Staff interviews confirmed that there were not enough CNAs on duty to meet residents' needs in a timely manner, and that they were instructed not to interrupt feeding to provide toileting assistance. Facility policies reviewed by the surveyor required prompt response to residents' requests for toileting assistance and call lights, and prohibited practices that compromise resident dignity. Despite these policies, staff actions and statements indicated that care was delayed due to staffing shortages and prioritization of other tasks, resulting in residents' needs not being met in a manner that promotes dignity and respect.