Failure to Ensure Resident Dignity and Personal Hygiene Due to Insufficient Staffing
Penalty
Summary
Surveyors identified that the facility failed to honor residents' rights to a dignified existence by not ensuring that multiple residents were well-groomed, clean, and dressed appropriately for the day. Observations revealed that several residents, all with significant cognitive impairments and dependent on staff for activities of daily living (ADLs), were left with uncombed hair, wrinkled or stained clothing, and food debris on their bodies and wheelchairs. In several instances, residents were left unattended in the activity room or in their own rooms without engagement in activities, and without staff present to assist or interact with them. Some residents were observed with visible food residue around their mouths after meals, and one resident was left in an uncomfortable, slouched position in a recliner with water out of reach. Interviews with multiple Certified Nurse's Aides (CNAs) consistently indicated that there was insufficient staffing to complete all required resident care, particularly for those needing two-person assistance for transfers. CNAs reported that the lack of adequate staff made it difficult to provide timely morning hygiene and personal care, resulting in residents being brought to breakfast and activities without being properly groomed or cleaned. Staff also noted that administrative personnel did not assist with resident care, and that the current staffing levels did not allow for the completion of all necessary ADLs and personal hygiene tasks. Administrative staff expressed differing views on staffing adequacy, with some acknowledging ongoing struggles to maintain sufficient staffing and others stating that staffing was appropriate. Despite this, administrative staff confirmed that a majority of residents required extensive assistance for transfers and ADLs. Facility policy required sufficient nursing staff to meet the needs of residents based on their acuity and care plans, but observations and staff interviews demonstrated that these standards were not being met, resulting in compromised resident dignity and psychosocial well-being.