Failure to Support Resident Choice and Self-Determination Due to Staffing Shortages
Penalty
Summary
The facility failed to honor and facilitate resident self-determination and choice for four residents, as evidenced by multiple instances where residents were not given the opportunity to make significant choices about their daily lives. Specifically, residents did not consistently receive showers or baths as scheduled in their care plans, were not transferred in and out of bed upon request, and were unable to participate in activities or go outside as specified in their care plans. These deficiencies were substantiated through record reviews, resident and staff interviews, and direct observations. One resident with diagnoses including dysphagia, rheumatoid arthritis, and depression reported only receiving one shower per week instead of the two scheduled, a fact confirmed by both the resident's POA and a CNA, who cited short staffing as the cause. Documentation showed that showers were missed on several scheduled days over multiple months. Another resident with multiple sclerosis, diabetes, and major depressive disorder stated they only received showers once a month, despite being scheduled for two per week. Documentation confirmed infrequent showers, and the resident was dependent on staff for transfers. A third resident with coronary artery disease, morbid obesity, heart failure, ESRD, and diabetes reported being unable to brush their teeth or access the toilet independently due to lack of staff assistance, resulting in long waits for perineal care and infrequent showers. Documentation supported these claims, showing minimal oral and personal hygiene care provided. A fourth resident with Type 2 diabetes, ESRD, hemiplegia, and PTSD stated they could not be transferred out of bed when requested and missed activities due to insufficient staff. Staff interviews and documentation confirmed that staffing shortages led to delays and omissions in care, directly impacting residents' ability to exercise choice and participate in meaningful activities.