Failure to Maintain Resident Dignity, Timely Call Light Response, and Appropriate Pain Management
Penalty
Summary
Facility staff failed to maintain resident dignity and timely response to needs in multiple situations. One cognitively intact resident with osteoarthritis, chronic pain, and a history of a fall with fracture required assistance of one staff for toileting and transfers and was non‑weight bearing to the left lower leg while receiving therapy for a leg fracture. This resident reported that a CNA assisted her onto the toilet and left the room; after activating the call light within about five minutes, no staff responded for approximately 45 minutes, despite her roommate observing several staff walking past the room without answering the call light. The resident stated that the CNA who eventually responded was not assigned to her hall and that being left on the toilet for that length of time made her feel like no one cared about her. The same resident also reported that when she requested PRN pain medication for left leg pain rated at 7, staff told her she could not receive PRNs at that time because they could not locate the assigned LPN. When the LPN did respond, the resident stated the nurse was mean and intimidating, insisted she would receive Tylenol instead of the PRN narcotic ordered for higher levels of pain, and that this behavior caused the resident to avoid requesting narcotics when that nurse was on duty. The resident reported sitting and crying for two hours due to pain and experiencing breakthrough pain related to therapy, and stated she had informed the DON that she endured a lot of pain because the LPN did not administer the requested PRN medication. Additional dignity concerns were identified with other residents. One resident reported that staff frequently entered his room without knocking, and this was observed when a staff member entered during an interview to check his ice without knocking. Another resident reported that staff had been entering his room without knocking for a long time and that he was fed up; this was observed when three staff entered his room without knocking and interrupted an interview. During a lunch observation, a dependent resident with CVA, malnutrition, aphasia, dementia, severely impaired cognition, and total dependence on staff for eating was fed by a CNA who sat with her elbow on the table, head resting on her hand, did not look at or interact with the resident, mechanically placed food and a straw into the resident’s mouth, and rubbed her eye before resuming feeding without apparent hand hygiene. These actions and inactions occurred despite facility policies on promoting/maintaining resident dignity and call light response, and staff and DON statements that expectations included timely call light response, knocking and announcing before entering, and providing appropriate pain control and dignified, engaged feeding assistance.
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