Failure to Provide Dignified and Timely Personal Care
Penalty
Summary
The facility failed to provide personal care in a dignified manner for one resident and did not provide timely personal care and assistance for eight other residents. One resident with Parkinson's disease and heart failure, who was cognitively intact and required substantial assistance with toileting and hygiene, reported experiencing rough and hurried care from a female staff member. The resident described feeling as if he was 'thrown around in bed' during care, attributing the roughness to the staff being hurried rather than intentionally harmful. This resident reported such rough care occurred about once a week and expressed that it made him feel unimportant. The facility's Director of Nursing was still investigating the complaint at the time of the survey. Multiple residents reported issues with delayed responses to call lights and staff not returning to complete care after initially responding. Resident Council meeting minutes over several months documented ongoing complaints about long call light response times, inaccessible call lights, and staff turning off call lights without meeting residents' needs. Residents described situations where staff would turn off the call light, promise to return, but then fail to do so, resulting in extended waits for assistance with basic needs such as toileting, transfers, and obtaining water. Some residents reported having to wait up to an hour for assistance, which caused discomfort and anxiety, especially for those with a history of falls or medical conditions that made waiting particularly difficult. Interviews with residents revealed that these issues were not isolated incidents but occurred frequently and affected multiple individuals. Residents expressed frustration, anxiety, and feelings of being forgotten or unimportant due to the delays and lack of follow-through by staff. The facility's policy required call lights to remain on until the resident's needs were met, but documentation and resident reports indicated that this policy was not consistently followed. Staff training had been initiated to address the issue, but residents continued to report problems with call light response and the manner in which care was provided.