Failure to Ensure Dignified Care and Communication for Residents
Penalty
Summary
The facility failed to ensure that residents' rights to a dignified existence, self-determination, and effective communication were upheld for two residents. One resident, who was completely dependent on staff due to quadriplegia and had no cognitive impairment, reported feeling disrespected and demoralized when staff providing incontinent care communicated only in Spanish, a language she did not understand. Despite her care plan specifying that staff should converse with her during care, bilingual and Spanish-only speaking CNAs conversed with each other in Spanish and did not translate their communication for the resident. The resident expressed frustration and a sense of isolation, as she was unable to communicate her needs or preferences effectively, particularly regarding the quality of her care. Another resident, with a history of cardiomyopathy, diabetes, and moderate cognitive impairment, reported experiencing numbness in her left arm and leg, as well as chest pain, to both day and night nursing staff. Despite these reports, there was no documentation in the resident's progress notes regarding these symptoms, nor evidence that nursing staff assessed her, notified a physician, or took further action. The resident expressed feelings of sadness and questioned whether she mattered, as she had not received feedback or follow-up from the nursing staff regarding her health concerns. Interviews with facility leadership confirmed that staff did not follow established policies requiring communication in a language residents understand and prompt reporting and documentation of changes in condition. The Director of Nursing acknowledged that the lack of action in response to the resident's reported symptoms was inappropriate and could have jeopardized the resident's health. The facility's own policies emphasized the importance of respect, dignity, and communication, but these were not followed in the care of the two residents involved.