Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
The facility failed to honor the rights of four residents to a dignified existence and self-determination, specifically regarding timely toileting assistance and the imposition of smoking restrictions. Two cognitively intact residents, both with documented needs for staff assistance with toileting, reported frequent delays in call light response, sometimes waiting up to thirty minutes for help. These delays resulted in incontinent episodes, as confirmed by both residents and staff, who acknowledged insufficient staffing, particularly on nights and weekends. Facility policy requires prompt response to call lights, but this was not consistently followed. Additionally, the facility implemented a blanket policy requiring all residents who smoke to wear plastic safety aprons and to smoke only under supervision, following an incident where one resident burned himself. Multiple residents, including those assessed as safe to smoke independently and with no history of burns, were required to wear the aprons and had their smoking paraphernalia locked away. These residents expressed discomfort and dissatisfaction with the new restrictions, stating they had not been reassessed individually after the incident and did not understand the need for the change. Staff interviews confirmed that the decision to require aprons and restrict smoking was made by facility administration after the burn incident, without individualized reassessment for each resident. Documentation showed that some residents' care plans and smoking safety screens did not indicate a need for adaptive equipment or supervision, yet the restrictions were applied universally. This resulted in a failure to respect residents' autonomy and dignity, as required by their rights.