Failure to Ensure Resident Dignity and Timely Assistance During Meals
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, as evidenced by multiple observed incidents involving five residents. One resident, who was visually impaired and dependent on staff for assistance, was left without her meal while her roommate was served, and was not assisted in finding or consuming her juice until prompted by a nurse. She expressed hunger and frustration at the delay, and indicated she was accustomed to eating with her fingers due to lack of assistance. Another resident, who was NPO and receiving tube feeding, was found with a cup containing urine at his bedside, which staff initially mistook for broth or water. Despite being NPO, the nurse offered to bring him ice water and discussed breakfast, which he could not have, demonstrating a lack of awareness of his dietary restrictions and needs. A third resident was dismissed by a receptionist when expressing hunger, with the staff member stating the resident could not be hungry after lunch. The resident was left in the hallway until a nurse aide intervened to check her meal intake and offer a snack. In another case, a resident with difficulty self-feeding was left without assistance for over 20 minutes, during which she attempted to eat with her fingers, sucked on her clothing protector, and tried to pick up food from the tablecloth. Assistance was only provided when the interim DON arrived and helped her eat. Additionally, a resident was observed feeding herself with a butter knife, and only received redirection and appropriate assistance after more than 20 minutes. These incidents collectively demonstrate a pattern of staff inaction, lack of timely assistance, and failure to recognize or respond to residents' needs, resulting in compromised dignity and respect for the affected individuals.