Failure to Promote Resident Self-Determination and Maintain Respectful Environment
Penalty
Summary
The facility failed to promote residents' right to self-determination and maintain a respectful environment, as evidenced by multiple observations and interviews. Four cognitively intact residents who dined in the east dining room reported being unaware of planned meal options or available food choices until meal service began. Observations confirmed that menu choices were not posted in the east dining room, and staff did not consistently ask residents about their meal preferences prior to serving. There was also confusion among staff regarding who was responsible for offering meal choices, and meal identification tray cards were not being used as required. Additionally, the dietary manager (DM) was reported by staff and residents to have yelled and used foul language in front of residents and other staff members. Several staff members described incidents where the DM was verbally aggressive, used profanity, and displayed disruptive behavior such as slamming items. Residents witnessed these outbursts, which made them feel uncomfortable and concerned for the staff involved. Some staff reported these incidents to management, while others did not, and there was a lack of documentation regarding the facility's response to these events. The facility's policies require that all residents be treated with kindness, respect, and dignity, and that staff model effective communication. Despite these requirements, the DM's behavior and the lack of clear communication regarding meal choices resulted in residents not being fully supported in exercising their rights. The events described involved residents who were cognitively intact and able to express their preferences and concerns, yet their rights to self-determination and a respectful environment were not upheld.