Failure to Timely Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of several residents by not providing timely personal care and meal service. Multiple residents reported significant delays in receiving assistance after activating their call lights. One resident, who was cognitively intact and required assistance with toileting, waited over an hour to be changed despite repeated requests and call light activations. Staff were observed turning off call lights without providing the requested care, and one certified nursing assistant stated that residents were not changed until after breakfast was served to avoid disturbing others. Another resident, dependent on a ventilator and requiring full staff assistance for activities of daily living, reported that staff responded to her needs only at their convenience, which increased her anxiety. A third resident, also cognitively intact and needing maximal assistance for transfers, described waiting over 30 minutes for help and sometimes experiencing even longer delays, attributing this to possible short staffing. In addition to delays in personal care, the facility did not provide meals to residents in a timely manner. Observations showed that breakfast trays were left in the hallway for an extended period before being distributed, resulting in residents receiving cold food. One resident reported that his eggs were ice cold and that trays were always cold, while another resident stated during a council meeting that meal trays were often delayed and cold when finally delivered. Staff interviews confirmed that meal trays should be distributed immediately upon arrival to the unit, but this was not consistently done. Facility policies reviewed during the investigation required that call lights be answered within a reasonable time and that incontinence care be provided while maintaining resident dignity. Staff interviews, including those with the DON and Director of Staff Development, confirmed that the expectation was for prompt response to call lights and immediate distribution of meal trays. However, the observed and reported practices did not align with these policies, resulting in unmet resident needs and delays in essential care and services.