Failure to Promote Resident Dignity and Timely Care
Penalty
Summary
Facility staff failed to promote the dignity of two residents by not honoring their rights to self-determination and timely care. For one resident with a diagnosis including major depressive disorder and who was cognitively intact, staff instructed her not to place personal items, such as bottles of water and a stuffed animal, on a shelf in front of her room window. The resident reported being told by staff that this was not allowed, citing safety and fire hazard concerns. However, the director of maintenance confirmed that the shelf was attached to the wall and that items would not rest on the air conditioning unit, and the regional director of clinical services stated it was not a fire hazard and that residents were allowed to place items in their windows. For another resident with swallowing difficulties and a history of stroke, who was also cognitively intact and required total assistance with activities of daily living, staff failed to provide a meal in a timely manner. The resident was observed with a lunch tray on the over-bed table, stating he had not eaten and was waiting for assistance. Staff interviews revealed that meal trays for residents needing assistance were left on the cart to stay warm and distributed after other residents were served. The CNA assigned to feed the resident was delayed due to other care tasks and assumed someone else had assisted the resident when the tray was not found on the cart. Both incidents were brought to the attention of facility leadership, including the administrator, director of nursing, assistant administrator, regional director of clinical services, and regional vice president. The facility's policy affirms residents' rights to be treated with respect, kindness, and dignity, which was not upheld in these cases.