Failure to Ensure Resident Dignity and Timely Assistance with Call Lights and Toileting
Penalty
Summary
Surveyors identified multiple failures by facility staff to honor residents' rights to dignity, self-determination, and communication. Several residents, all dependent on staff for activities of daily living (ADLs) due to complex medical conditions such as heart disease, kidney disease, cognitive impairment, and mobility limitations, were observed without accessible call lights or experienced extended call light response times. In some cases, residents were unable to reach their call lights, were unaware of their location, or reported that staff did not respond in a timely manner. Family members corroborated these accounts, with one family member stating they had to provide incontinence care themselves due to staff inaction. Resident Council meeting notes further documented widespread complaints about delayed call light responses, with reports of waits exceeding an hour and staff not meeting residents' needs. Additional deficiencies were observed in the provision of toileting and personal care. One resident, dependent on staff for toileting and personal hygiene, was left soiled and told to wait for assistance until after eating, despite having both urinary and fecal incontinence. The resident was observed attempting to eat without adaptive equipment, with food spilled on their clothing and a strong odor of bowel movement present. Staff were unable to identify who delivered the food tray or provide timely incontinence care, contrary to the resident's care plan, which required routine checks and assistance with toileting and eating. Another resident was observed with their pants down, exposed to the hallway while attempting to access the bathroom independently, indicating a lack of timely staff assistance with toileting and a failure to maintain the resident's dignity and privacy. These incidents, supported by resident interviews, observations, and care plan reviews, resulted in residents experiencing fear of abandonment, anger, skin irritation from prolonged exposure to urine and feces, and embarrassment.