Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents in several key areas. One resident, who was cognitively intact and dependent on staff for most activities of daily living, developed Moisture Associated Skin Damage (MASD) in the peri-area. This was attributed to prolonged exposure to urine, as documented in progress notes and a change of condition report. The resident and her family reported that certified nursing assistants (CNAs) did not change her throughout the night, and grievances were filed regarding the lack of timely incontinence care. Staff interviews confirmed that the resident was sometimes left uncleaned overnight, and that perineal care protocols were not consistently followed. Additionally, the same resident's family experienced repeated difficulties contacting her by telephone while she was in the facility. Grievance reports and interviews revealed that calls to the facility often went unanswered, particularly after receptionist hours, due to technical issues with the phone system and lapses in call transfer procedures. The family reported making numerous unsuccessful attempts to reach the facility, and staff acknowledged that calls were not always picked up or properly routed to the nursing station after hours. Both this resident and another resident were affected by ongoing issues with call light response times. Resident council meeting minutes and grievances documented that call lights were not answered promptly, with some residents waiting up to two hours for assistance and concerns about call lights being disconnected. Staff interviews confirmed that all staff were responsible for answering call lights, but this was not consistently done. Facility policies required timely response to call lights and emphasized the importance of maintaining resident dignity and respecting resident rights, but these standards were not met in practice.