Failure to Ensure Timely Care and Resident Dignity
Penalty
Summary
The facility failed to promote a dignified environment and provide timely care and services to residents, as evidenced by multiple instances of delayed response to call lights and failure to ensure residents were appropriately dressed. Several residents, both cognitively intact and impaired, reported or were observed experiencing significant delays in staff response after activating their call lights, with some waiting up to an hour or more for assistance. In one case, a resident was observed with her call light on for approximately 20 minutes, sitting on the edge of her bed with her underwear pulled down, while staff walked past without responding. Other residents reported similar delays, particularly during high care activity times or meal service, with one resident being told she would have to wait until meal service was completed before receiving pain medication. Resident council meeting minutes from several months documented ongoing concerns from residents about slow call light response times. Despite staff education and in-service training on the importance of timely call light response, residents continued to voice dissatisfaction with the timeliness of care. The facility's own policy set a goal of answering call lights within 10 minutes, but this standard was not consistently met, as confirmed by both resident interviews and direct observation by surveyors. Additionally, the facility failed to ensure that residents were dressed in street clothes while dining in the facility dining room. One resident was observed sitting in a wheelchair in the dining room and later in her room, dressed only in a hospital gown with part of her back exposed, despite having clothing available and expressing a desire to be dressed. This lack of attention to residents' dignity and personal preferences further contributed to the deficiency, as it did not align with the facility's policy to promote a dignified existence and respect for residents' individuality.