Failure to Ensure Resident Dignity, Timely Assistance, and Communication Rights
Penalty
Summary
The facility failed to ensure that residents received care and services that supported a dignified existence and effective communication with friends and family, as evidenced by multiple observations and interviews. One resident with diagnoses including Multiple Sclerosis, COPD, and PTSD, and with intact cognition, was observed left alone in the dining room leaning significantly to one side in her wheelchair, unable to reach her food or reposition herself. Staff present in the dining area did not assist or seek help, and when a CNA eventually intervened, the staff member spoke to the resident in a disrespectful manner, blaming her for moving a pillow that was supposed to support her posture. The resident confirmed that she often leaned due to her condition and was unable to reposition herself, and that staff sometimes blamed her for her positioning issues. Additionally, her call light was not within reach, and she indicated she would have to yell for help if needed. Another resident, also with intact cognition and a history of anxiety, depression, and repeated falls, reported experiencing long wait times for call lights to be answered, resulting in an incontinence episode that soaked through her clothing. She also described a lack of respect for her personal schedule, such as being put to bed earlier than she wished, and noted that her bed was often left unmade after outings. Staff interviews confirmed that call light response times were a recurring issue, with expectations set at 15 minutes or less, but complaints about delays were common among residents. A third resident, with moderate cognitive impairment and a history of anxiety and depression, was denied regular phone communication with family members. Family members reported being unable to reach the resident by phone for extended periods, with staff informing them that the resident was unavailable due to eating or sleeping, without always giving the resident the choice to take the call. The resident was unaware that she could use the facility phone to call her family. Staff interviews revealed inconsistent practices regarding informing residents of incoming calls and providing access to phones, with some staff basing decisions on whether the caller was a Power of Attorney. The facility's policy emphasized the right to dignity, respect, and communication, but these rights were not consistently upheld for the residents involved.