Failure to Maintain Resident Dignity, Timely Care, and Privacy
Penalty
Summary
Multiple residents experienced a lack of dignity and respect due to staff actions and inactions, as evidenced by resident council meeting notes, direct observations, and interviews. Residents reported that staff would enter rooms, turn off call lights without providing the requested care, and leave without returning, resulting in residents waiting one to two hours for assistance. Staff were also described as speaking disrespectfully, being rude, and using earbuds or phones while providing care. Additionally, staff were overheard discussing residents' personal care needs loudly in hallways, including using residents' names and making derogatory comments about care tasks they did not want to perform. These issues were reported to occur more frequently during evening, night, and weekend shifts. Direct observations confirmed that call lights for two residents remained unanswered for extended periods, with one resident waiting approximately 30 minutes before staff entered the room and another waiting nearly two hours to be cleaned up. One resident was found with his pants down and without a privacy curtain available, indicating a lack of bodily privacy. Another resident reported waiting an hour and a half after her call light was answered before being assisted to bed, resulting in discomfort. Staff were observed engaging in personal conversations and not prioritizing resident care needs, while some staff were unaware of residents' care requirements during their assigned shifts. Resident council meeting minutes from several dates documented ongoing concerns about untimely call light responses, staff being distracted by phones and earbuds, and unkind or disrespectful behavior. Residents also reported that their concerns had been brought to management but remained unresolved. Facility policies reviewed by surveyors emphasized the importance of dignity, respect, privacy, and timely assistance, but these standards were not consistently upheld for the residents involved.