Failure to Honor Resident Rights and Dignity
Penalty
Summary
The facility failed to honor residents' rights to dignity, respect, and self-determination in several ways, as evidenced by multiple incidents involving six residents. One cognitively intact resident was removed from a group activity and brought into a meeting with four department heads without prior notice or the opportunity to have a family member present. The meeting was prompted by the resident's voiced concerns about food quality and a family member's social media post about the food. The resident reported feeling intimidated and uncomfortable during the meeting, and staff acknowledged that the approach could have been perceived as intimidating. Documentation also showed that the resident did not initiate or sign a grievance form about the food, despite the form indicating otherwise. Another resident with severe cognitive impairment and dependent on staff for toileting was put to bed without being offered the opportunity to use the toilet, resulting in incontinence and soiled clothing and bedding. The CNA responsible stated that there was insufficient staff available to assist with toileting at the time, and the resident's private caregiver found the resident wet the following morning. Staff interviews confirmed that staffing shortages often led to delays in providing care, and the Director of Nursing acknowledged that this was unacceptable and that licensed nurses were expected to assist when needed. Additional residents reported long wait times for call lights to be answered, sometimes resulting in incontinence episodes. Staff and CNAs confirmed that frequent staffing shortages made it difficult to meet residents' needs in a timely manner. One resident also reported that staff stored their personal belongings in his room without his consent, which he found distressing. Staff admitted to using residents' closets for personal items despite the availability of staff lockers and break rooms, and facility leadership confirmed that this practice was inappropriate. Facility policies reviewed emphasized the importance of treating residents with dignity, respect, and privacy, but these standards were not consistently upheld.