Failure to Ensure Resident Dignity, Self-Determination, and Access to Services
Penalty
Summary
Surveyors identified multiple deficiencies related to residents' rights to dignity, self-determination, and communication. One resident reported that care plan meetings were held at bedside with only a social worker present, and that they received only a care plan report and grievance form without meaningful discussion or support from other staff. The resident also experienced missed medical appointments for over a year due to the facility providing a replacement wheelchair that was too large for available transportation, despite being approved for a power wheelchair that was never received due to unpaid facility bills. The resident further reported a lack of support in discharge planning to return to their home state, loss of access to personal funds after the facility became their Social Security Representative Payee without proper communication or documentation, and an inability to obtain personal documents or legal assistance due to lack of funds. Record reviews confirmed the resident was cognitively intact and had decision-making capacity, yet the facility initiated the payee process citing incapacity, and failed to provide statements or timely access to personal funds. Surveyors also observed staff repeatedly entering residents' rooms without knocking or requesting permission, despite previous resident complaints and administrative awareness of the issue. Multiple residents confirmed that staff often failed to announce themselves before entering, and this concern had been reported to facility administration but remained unresolved. Direct observations by surveyors corroborated these reports, with staff entering rooms unannounced during the survey period. Additionally, residents reported not having access to their personal clothing, particularly on weekends, due to ongoing staffing shortages in the facility's laundry services. One resident was found to have no clothing in their room except for the outfit they were wearing, which they had slept in, while another was observed wearing a hospital gown and expressed a preference for personal clothing. The Director of Housekeeping confirmed that the position responsible for laundering personal items on weekends had been unfilled for months, resulting in extended wait times for laundry return and residents lacking appropriate clothing.