Failure to Honor Resident Preferences for Call Light and Diet
Penalty
Summary
The facility failed to honor a resident's preferences as requested, specifically regarding the use of a call light system and dietary accommodations. The resident, who had multiple diagnoses including interstitial pulmonary disease, chronic respiratory failure, and neuropathy, required assistance with activities of daily living and had intact cognition. The care plan indicated that a soft touch pad call light should be clipped to the resident's gown at all times due to dexterity issues. However, observations and interviews revealed that the resident only had access to a push button call light, which was difficult for her to use, and the requested call pad was not provided. Staff interviews confirmed awareness of the resident's preference and the facility's agreement to provide the call pad, but it was not implemented. Additionally, the resident's dietary preferences were not honored. The resident was on a minced and moist diet with specific instructions to avoid bread and to have biscuits mashed with gravy. A photo submitted by the resident's daughter showed a roll on the resident's plate, contrary to the dietary order. The Food Service Director confirmed that the meal did not comply with the resident's preferences as documented. Facility policies required evaluation of unique resident needs and prompt reporting and resolution of issues with accommodations, but these were not followed in this case.