Failure to Uphold Resident Dignity in Meal Service and Room Care
Penalty
Summary
The facility failed to treat several residents with respect and dignity, as required by resident rights policies. Specifically, staff did not ensure that all residents seated at the same dining table were served their meals at the same time. One resident was observed eating lunch while two other residents at the same table waited to be served, with one resident expressing discomfort at having to watch another eat before receiving her own meal. Another resident, who was nonverbal, indicated agreement with this sentiment through gestures. Staff interviews confirmed that the expectation is for all residents at a table to be served simultaneously, but this was not consistently practiced due to the way trays were distributed from the kitchen. Additionally, the facility failed to make up a resident's bed in a timely manner, despite repeated requests from the resident. The resident, who has quadriplegia and no cognitive impairment, reported that her bed was often left unmade until late in the day, sometimes as late as 6:00 p.m. or 8:00 p.m., which interfered with her preferred bedtime and caused her embarrassment when visitors arrived. Observations confirmed that the bed remained unmade well into the afternoon, and staff interviews revealed a lack of consistent follow-through on making beds before lunchtime, as required by facility policy. The residents involved had significant medical conditions, including heart failure, hypertension, diabetes, aphasia, stroke, depression, and quadriplegia. Despite these needs, the facility did not uphold their rights to a dignified environment and timely care. Staff and administration acknowledged awareness of the policies but did not ensure their consistent implementation, resulting in residents feeling their dignity was compromised.