Failure to Honor Resident Rights and Dignity: Delayed Call Light Response and Unmet Preferences
Penalty
Summary
The facility failed to maintain residents' rights and dignity by not ensuring timely response to call lights, not keeping call lights within residents' reach, not providing meals and snacks according to residents' preferences, and not maintaining adequate lighting in a resident's room. Multiple residents reported or were observed to have call lights out of reach, resulting in them having to yell for assistance or wait extended periods, sometimes over 30 minutes or even an hour, before receiving help. In one instance, a resident was unable to access the call light and had to rely on shouting for staff, while another resident's family member reported that the call light was activated but not answered in a timely manner, leading to incontinence due to the delay. Residents also reported issues with meal service, including not receiving meals or snacks as ordered, receiving cold or incorrect food, and not having their dietary preferences honored despite repeated requests. One resident was documented as missing meals for two days, with no record of meal intake or snacks provided on certain days, and experienced significant weight loss during their stay. Another resident repeatedly received food items they disliked or had specifically requested not to receive, such as white bread instead of wheat bread, or fish and zucchini despite these being listed as dislikes on their meal slip. Additionally, the facility did not ensure that environmental needs were met, as evidenced by a resident's request for a working light above their bed, which was found to be nonfunctional with exposed wires and no bulb. Staff interviews confirmed that call lights were not always left on until needs were met, and that residents sometimes received whatever food was being served rather than their stated preferences. Facility policies reviewed indicated requirements for timely meal service, honoring resident preferences, and maintaining dignity, but these were not consistently followed as observed and reported.