Failure to Support Resident Choice in Daily Care and Positioning
Penalty
Summary
The facility failed to honor and support resident self-determination and choice for two residents. One resident, who prefers to brush her teeth three times a day, specifically upon waking and after each meal, reported that staff often delayed assisting her with oral hygiene until late morning or even around lunchtime, despite her preference for morning care. Documentation of oral hygiene tasks confirmed that assistance was most frequently provided in the late morning or afternoon, rather than at the times preferred by the resident. The Director of Nursing acknowledged that the timing of oral care did not align with the resident's stated preferences. Another resident, who is on hospice care and has a weakened physical state, was observed seated in a wheelchair in the dining room for extended periods, including sleeping in the chair, despite family and resident representative requests that the resident not remain in the wheelchair for more than 15-20 minutes at a time. Family members and the resident representative reported that the resident could not tolerate prolonged periods in the wheelchair and had communicated this to staff. Observations and interviews confirmed that the resident was left in the wheelchair for longer than requested, and the Director of Nursing confirmed this was not in accordance with the family's wishes.