Failure to Provide Dignified Dining Experience and Communication
Penalty
Summary
Staff failed to treat two residents with dignity during the dining experience. One resident, who had dysphagia, feeding difficulties, muscle weakness, and required set-up assistance for self-feeding, was observed repeatedly calling for help and signaling staff by waving an empty coffee cup in the day room after breakfast. Multiple staff members entered and exited the room, removed items from the resident's tray, and turned on the television, but none acknowledged or responded to the resident's requests for assistance. The resident's care plan indicated that staff should anticipate and meet needs, and encourage the resident to communicate needs for safety, but these interventions were not followed. Another resident, with diagnoses including dysphagia, dementia, diabetes, and severe cognitive impairment, was observed during breakfast sitting alone with a tray not set up for consumption and no staff present to assist. When a CNA eventually arrived to feed the resident, there was no attempt to communicate with the resident in their preferred language, Haitian/Creole, despite the CNA being able to speak it. The CNA only spoke in English and did not engage the resident throughout the meal. Later, a nurse also fed the resident without attempting communication in the resident's language, only briefly asking a question in English. The resident's care plans specified the need for patience, use of simple questions, and communication in French Creole, but these were not implemented. Interviews with staff confirmed that they were aware of the residents' communication needs and language preferences, and that some staff could speak Haitian/Creole. However, staff did not use available communication tools or methods, such as cue cards or language lines, and did not attempt to communicate with the resident in their preferred language during meals. The DON stated that staff are expected to communicate with residents in their preferred language and provide appropriate supervision and care during meals.