Failure to Ensure Resident Dignity and Prompt Care
Penalty
Summary
Surveyors identified that the facility failed to ensure residents' rights to dignity and prompt care for three residents. One resident, who was cognitively intact and required substantial assistance with toileting due to frequent incontinence, reported that a night shift nurse aide repeatedly made her wait for incontinence care, telling her that regulations required care only every two hours and that the previous shift should have addressed her needs. The resident described feeling forgotten and tracked the aide's response times on her phone. The nurse aide confirmed informing the resident about the two-hour schedule and deferring care, while nursing staff were unaware of the resident's concerns. Another resident, also cognitively intact and dependent on staff for toileting due to paraplegia, reported frequent delays in care during the night shift, with wait times of up to 1.5 hours. This resident stated that the same nurse aide told him that state law only required changes every two hours and would defer care requests until scheduled rounds. The resident described an incident where his call light was turned off without care being provided, and when care was eventually given, it was incomplete, as the aide only changed his brief without cleaning him. Nursing staff were again unaware of these concerns, and another aide reported no knowledge of care being withheld. A third resident, who was moderately cognitively impaired and required assistance with activities of daily living, alleged that a nurse aide was aggressive during care, including pushing him onto the bed, throwing a brief at him, and telling him to change himself. A former roommate corroborated the account, stating that the aide yelled at and pushed the resident. The aide denied physical aggression but admitted to raising her voice due to the resident's hearing impairment. The resident's care plan included specific communication interventions due to his hearing loss, but these were not followed during the incident.