Failure to Honor Resident's Choice to Return to Room
Penalty
Summary
A resident under the age of 65 with a history of traumatic brain injury, post-traumatic seizures, and chronic respiratory failure, who was cognitively intact and dependent on staff for activities of daily living, was not assisted to return to his room despite multiple requests. During a continuous observation in the dining room, the resident initially asked a staff member to help him return to his room and was told to wait 15 minutes due to room cleaning. Over the next hour, the resident made repeated requests to various staff members, including housekeeping, the activities director, and kitchen staff, but was not assisted. Some staff did not respond, while others said they would find help but did not follow through. The resident became increasingly distressed, eventually shouting and expressing a desire to leave the dining room. The resident later reported that he often had to wait long periods to return to his room, which made him feel bad. The nursing home administrator confirmed that the facility should have honored the resident's choices and indicated that the staff member who initially told the resident to wait likely forgot to follow up. The facility failed to facilitate the resident's self-determination and did not honor his choice to return to his room for over an hour after his initial request.