Failure to Protect Residents from Neglect and Unsympathetic Staff Attitudes
Penalty
Summary
Surveyors identified multiple failures by facility staff to protect residents from neglect and unsympathetic or negative staff attitudes, resulting in emotional and psychological distress. One resident, with moderate cognitive impairment and significant physical care needs, was observed waiting over 1.5 hours for toileting assistance despite repeated requests for help. The resident expressed fear of staff retaliation if her needs were reported, and staff members failed to respond to her call light in a timely manner, even after being made aware of her request. Documentation confirmed the resident required total assistance for toileting, and staff interviews acknowledged that the wait time was excessive and unacceptable. Additional residents reported negative interactions with staff, including a CNA who was described as rude, rushed, and rough during care. One resident recounted an incident where a CNA was on the phone during care and became snappy when questioned, leading the resident to feel uncomfortable and fearful of future interactions. Another resident described being handled roughly by the same CNA, resulting in visible bruising, and expressed fear of retaliation if she reported the behavior. These residents had not filed formal grievances, often citing fear of staff reprisal. Interviews with staff and facility leadership revealed gaps in the investigation and resolution of grievances. The Risk Manager stated that grievances were not pursued if residents denied explicit abuse, without considering fear of retaliation or psychological impact. The Staff Development Coordinator acknowledged ongoing issues with staff attitudes and bedside manner, and some CNAs reported not receiving customer service training. Facility policies required prompt investigation and resolution of grievances and mandated reporting of suspected abuse or neglect, but these procedures were not consistently followed, contributing to the ongoing deficiencies.