Failure to Ensure Resident Dignity and Respect During Meal Service and Room Entry
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect during multiple observed incidents involving two residents. One resident, who was severely cognitively impaired, totally dependent on staff for self-care and mobility, and exhibited continuous inattention and disorganized thinking, experienced significant delays in meal service and was left unattended for extended periods. Observations showed the resident was brought to the dining room and left without food for up to 37 minutes before being served, and on another occasion, was seated facing a wall with minimal engagement or supervision. Staff interviews confirmed that only one person was assigned to the dining room during meal service, despite the need for more staff to assist residents who required help with eating, resulting in residents having to wait for assistance. Another resident, who was assessed as independent in decision-making but had a care plan for hoarding behaviors, was upset after facility staff entered their room and removed personal items while the resident was hospitalized. The NHA had directed the social worker to inform several residents, including this one, that their rooms needed to be cleaned due to fire hazard concerns. The EVS manager, following the NHA's instructions, entered the resident's room without consent and removed items belonging to the facility, such as linens and clothing protectors. The resident expressed distress over the lack of consent and the handling of their personal belongings. These incidents were corroborated by staff interviews and documentation, which revealed that the facility's actions did not align with the residents' rights to dignity, respect, and involvement in decisions about their care and personal property. The lack of adequate staffing during meal times and the unauthorized entry into a resident's room while absent were key factors leading to the deficiencies identified by surveyors.