Failure to Maintain Resident Dignity and Timely Care
Penalty
Summary
The facility failed to ensure that residents dependent on staff for care were treated in a dignified manner, as evidenced by multiple incidents involving three residents. One resident, who was cognitively intact and required assistance with transfers and toileting, reported that her dressing changes were routinely performed in the middle of the night, disrupting her sleep. She expressed that only her pain medication was needed at those hours, and that dressing changes should be done before bedtime. Despite raising these concerns in a care conference, the issue persisted, and she also experienced significant delays in call light response, sometimes waiting up to 50 minutes for assistance with toileting, resulting in incontinence and distress. Another resident, who required assistance with activities of daily living, reported that her call light was not answered in a timely manner, often taking an hour or more. On one occasion, staff walked past her room while her call light was on and told her they could not help, leaving her feeling ignored and devalued. The DON acknowledged that this response was inappropriate and that staff should have communicated with the resident about when assistance would be provided. A third resident, who was dependent on staff for personal hygiene, was observed to have visible patches of facial hair, which her daughter stated would have been distressing to her. The resident had an electric razor in her room, but staff had not assisted her with shaving, possibly due to her refusal of showers. The DON agreed that this was a dignity issue and that staff should have addressed her facial hair between showers if needed. Facility policies reviewed emphasized the importance of treating residents with dignity and respect at all times.