Failure to Ensure Resident Dignity and Effective Communication
Penalty
Summary
The facility failed to ensure that residents' rights to dignity, self-determination, and effective communication were upheld, as evidenced by two separate incidents involving two residents. In the first incident, a resident with multiple medical diagnoses, including schizophrenia, COPD, and malnutrition, was observed sitting at a dining table with another resident. While the other resident received his meal promptly, this resident waited for approximately nine minutes without being served, despite inquiring about his meal. Staff continued to serve other residents before eventually providing the meal, resulting in the resident watching his tablemate finish eating before he received his own tray. Facility policy and the Director of Nursing both confirmed that residents seated at the same table should be served at the same time to maintain dignity and a homelike environment. In the second incident, a resident with highly impaired hearing and absence of speech was not provided with effective and accessible means of communication. The resident's care plan indicated the need for communication aids such as cue cards and a communication board, but these were not available or accessible in the resident's room. Staff interviews revealed that none of the staff had received training in sign language, and most relied on gestures or facial expressions to communicate. The communication board was found attached to the wall and could not be detached for use, and cue cards were not present. The resident confirmed that he did not use the communication board or cue cards. Facility policies required that meals be served in a manner that respects residents' dignity and that communication aids be made available for residents with communication needs. Despite these policies and recent in-service training for staff on meal service and seating arrangements, the facility did not ensure that these standards were met for the affected residents, resulting in a failure to honor their rights to dignity and effective communication.