Failure to Respond Timely to Call Lights Resulting in Prolonged Incontinence and Loss of Dignity
Summary
The deficiency involves the facility’s failure to honor residents’ rights to timely care and dignified treatment by not responding promptly to call lights, particularly on the North Hall. Multiple cognitively intact or moderately impaired residents who were dependent on staff for toileting and repositioning reported extended delays, often 30–60 minutes, before staff responded to their requests for assistance. These delays occurred despite care plan interventions that emphasized keeping call lights within reach and encouraging residents to use them for help, as well as documentation that several residents were incontinent and required extensive or total assistance with ADLs and toileting. One resident with chronic respiratory failure, type 2 diabetes, morbid obesity, chronic kidney and heart disease, and a history of moisture-associated skin damage reported that on an evening shift she waited over 30 minutes for her call light to be answered, and that such delays of 30 minutes to an hour happened frequently, especially in the evenings. This resident was bedbound, dependent on staff for toileting and repositioning, always incontinent of bowel, and at risk for impaired skin integrity, yet she reported that often only one CNA was assigned to her hall and one CNA to the other hall. Another resident with Parkinson’s disease, COPD, panic disorder, and fibromyalgia, who required assistance with ADLs and was occasionally incontinent, stated she had to wait over an hour on an evening shift for her call light to be answered while lying in a soaked bed and feeling cold from being in her urine. She reported that when still in her wheelchair, she would sometimes wheel into the hall to look for staff because of the delays. A third resident with permanent atrial fibrillation, chronic respiratory failure, type 2 diabetes, unsteadiness on feet, and chronic pain, who was always incontinent and dependent for toileting hygiene, stated she had her call light on several times one night and had to wait 30–45 minutes each time for staff to respond, during which she lay in urine while waiting to be changed. A fourth resident with hemiplegia, type 2 diabetes, COPD, morbid obesity, neurocognitive disorder with Lewy bodies, dementia with behavioral disturbance, Parkinson’s disease, and multiple other comorbidities, who was always incontinent and dependent for toileting and transfers, reported being on her call light for over 30 minutes one night, even calling the nurses’ station for help, while waiting to be changed after an incontinent episode. She stated that such delays in the evening occurred often and that it could take 30–45 minutes, sometimes an hour, for call lights to be answered. Surveyor observations and staff interviews corroborated these reports of delayed responses. On one evening, the DON stated that only two CNAs were working the floor, one CNA had called in, another had not shown up or called, and an agency nurse unfamiliar with the facility was the nurse on duty. The DON also stated another CNA was coming in later to help. During this time, the CNA assigned to the North Hall was observed taking residents outside to smoke, leaving no other CNA visible on that hall. Multiple call lights were observed activated in four separate rooms on the North Hall for an extended period while the CNA was outside and then occupied with other tasks, including taking vital signs on a resident in the dining room and answering the phone. An unknown resident was heard yelling for help from the North Hall while call lights continued to sound. The Administrator later stated he felt staff answered call lights in a timely manner but acknowledged that if only one CNA was on a hall, that CNA should not be taking residents out to smoke and leaving no staff on the hallway. The facility’s policy on answering call lights stated that the purpose of the procedure was to respond to residents’ requests and needs, but the observed and reported delays demonstrated a failure to follow this policy.
Penalty
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Failure to preserve dignity occurred when staff placed a brief on a cognitively intact resident who was continent of bowel and bladder. The resident stated the brief made him feel like a baby, and a NA confirmed she applied it even though he was not incontinent; RN and DON both verified the resident was continent and that briefs should not be placed on continent residents.
Failure to Knock Before Entering Rooms and Exposed Urinary Bag: A CNA entered three residents' rooms without knocking, and each resident said staff should knock and that they preferred privacy. The residents had diagnoses including encephalopathy, heart failure, respiratory failure, malnutrition, and sepsis, with moderate cognitive impairment documented for three of them. In addition, a resident with a urinary catheter was observed with an exposed urine bag hanging from the bed without a privacy cover, and the urine could be seen from the hallway; interviews confirmed privacy covers were required and that exposed urine affected dignity.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's dignity was not maintained during a blood sugar check when an RN performed the finger stick in the day room with two other residents and a visitor present and loudly announced the result. The RN did not ask permission before checking the resident's blood sugar in the common area, and the resident was described as alert, oriented, and new to the facility.
Cell Phone Use During Resident Care: CNAs were observed and reported using personal cell phones while providing care, including showers, in resident rooms, at nurses’ stations, in hallways, and while supervising smoking times. Nine confidential residents said the behavior made them feel ignored, embarrassed, and that their privacy was violated. The DON and ADM stated residents should receive privacy and full attention during care, and the facility policy required staff to treat residents with kindness, respect, dignity, privacy, and confidentiality.
Staff failed to maintain resident dignity during wheelchair transport and assisted feeding. A resident with dementia and severe cognitive impairment was transported in a geriatric wheelchair while facing backward, slumped over, and moaning as a CNA pulled the chair from the front, preventing the resident from seeing where he was going. Two cognitively impaired, fully dependent residents were assisted with eating by CNAs who stood over them rather than sitting at eye level, despite chairs being available in the room and dining area. One CNA reported not knowing she was expected to sit while feeding, and another stated she remained standing to monitor other residents who were self-feeding while she was the only staff member present.
Failure to Preserve Dignity by Placing a Brief on a Continent Resident
Penalty
Summary
The facility failed to provide services in a dignified manner for 1 resident who was cognitively intact and had diagnoses including renal insufficiency, DM, and hypertension. The resident’s MDS identified him as continent of bowel and bladder and needing staff assistance with ADLs including bed mobility, transfers, and toileting. A bowel and bladder assessment also identified the resident as continent, and the care plan stated he was aware of the need to void or defecate and would request to use the toilet as needed. During interview, the resident stated staff put diapers on him even though he was not incontinent and said it made him feel like a baby. During observation, a NA placed a brief on the resident, and the resident showed the surveyor the brief and stated it had just been put on him a few minutes earlier. The NA verified she placed a brief on the resident that morning even though he was not incontinent and said she was unsure why she did so. RN-A confirmed the resident was continent and stated staff put a brief on him out of habit. The DON stated staff should not place a brief on residents who are continent and that it was important to maintain the resident’s dignity.
Failure to Knock Before Entering Rooms and Exposed Urinary Bag
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity when CNA B did not knock before entering the rooms of Resident #20, Resident #59, and Resident #64. Resident #20 was a female with diagnoses including metabolic encephalopathy, hypertensive chronic kidney disease, hyperlipidemia, hypertension, weakness, and unsteadiness on feet, and her BIMS score was 08. Resident #59 was a female with diagnoses including heart failure, respiratory failure, muscle weakness, GERD without esophagitis, hypertension, and sepsis, and her BIMS score was 10. Resident #64 was a male with diagnoses including protein-calorie malnutrition, sepsis, hypertension, kidney failure, and alcohol abuse, and his BIMS score was 09. Each resident stated staff did not knock on the door and that they wanted staff to knock before entering their rooms. Observations during breakfast tray pass showed CNA B entering Resident #59's room at 7:17 a.m., Resident #64's room at 7:25 a.m., and Resident #20's room at 7:28 a.m. without knocking first. During interviews, Resident #59 said staff were supposed to knock and that staff would just walk in, including when she was being changed. Resident #64 said staff walked into his room all the time and that he got irritated when they did not knock. Resident #20 said staff never knocked on the door and that she preferred they knock, especially if the door was closed. The facility also failed to ensure Resident #102's urinary catheter had a privacy cover. Resident #102 was a female with diagnoses including hearing loss, pain, hypertension, cognitive communication deficit, and a rib fracture with pain, and her BIMS score was 99, indicating unable to complete the interview. Observations showed a urinary bag hanging from the side and bottom of her bed with no privacy cover, and the urine was visible from the hallway. Interviews with CNA B, MA F, CNA A, Central Supply, and the DON indicated privacy bags were supposed to be used for urinary bags and that exposed urine affected dignity and self-worth. The resident's care plan did not reflect anything about the catheter, and the report states the Dignity Policy required each resident to be cared for in a manner that promotes and enhances well-being, satisfaction with life, and feelings of self-worth and self-esteem.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Maintain Resident Dignity During Blood Sugar Check
Penalty
Summary
The facility failed to maintain a resident's dignity during a blood sugar check for Resident 97. During an observation on 5/1/26 at 11:21 a.m., RN 1 prepared to check the resident's blood sugar while the resident was sitting in her wheelchair in the day room with two other residents and a visitor present. RN 1 told the resident she was going to check her blood sugar, stuck the resident's finger, checked the blood sugar, and announced the result loudly in the common area. RN 1 did not ask the resident for permission to perform the blood sugar check in the common area with others present. During an interview later that day, Unit Manager 1 stated the resident was alert and oriented and new to the facility, and that they were working on a care plan indicating the resident was okay with having her blood sugar checked in common areas.
Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and care in a manner that promotes quality of life and recognizes each resident’s individuality for 9 confidential residents. The deficiency was based on resident interviews and record review showing that CNAs were using personal cell phones while providing care, including assisting with showers, performing care in resident rooms, and supervising residents during supervised smoking times. Residents stated staff texted and talked on their phones while walking in hallways, at nurses’ stations, and while performing care in their rooms, and they reported that this occurred on every shift and often in the facility. The residents also stated they did not know the names of the CNAs involved. The 9 confidential residents stated the cell phone use made them feel ignored, not a priority, embarrassed, and concerned that a CNA could make a mistake because of distraction. They also stated their privacy was violated. During interviews, the DON and ADM stated residents should receive privacy and full attention during care, and both stated staff were trained on privacy, resident rights, dignity, and cell phone usage. The record review included the facility policy titled Resident Rights, dated February 2021, which stated employees shall treat all residents with kindness, respect, and dignity and that residents have the right to a dignified existence, to be treated with respect, kindness, and dignity, and to privacy and confidentiality.
Failure to Maintain Resident Dignity During Transport and Assisted Feeding
Penalty
Summary
The deficiency involves failure to honor residents’ rights to dignity and respectful treatment during transport and meals. One resident with dementia, anxiety, severe cognitive impairment, and total dependence for ADLs was observed seated in a geriatric wheelchair, slumped over with his head hanging and eyes open, and moaning while a nurse aide pulled the chair down the hall from the front, causing the resident to face backward and be unable to see where he was going. The aide reported she pulled the chair because it was hard to push and acknowledged she had been educated on dignity and respect and should have pushed the resident in front of her, which would have allowed her to see his slumped posture and hear his moaning. The DON confirmed that the resident should have been pushed in front of the aide and that this was a dignity issue. The deficiency also includes failure to promote dignity during meals for two residents with severely impaired cognition who were dependent on staff for eating. One resident with a traumatic brain injury was observed in bed with the head of the bed elevated while an agency nurse aide stood over the bedside and assisted with eating without sitting at eye level, despite a chair being available in the room; the aide stated she had never heard of needing to sit to feed a resident and only sat after being questioned. The other cognitively impaired, fully dependent resident in a semi-reclined geriatric chair in the dining room was fed by the same nurse aide, who stood over the resident while feeding despite an empty chair being available; the aide later stated she believed she had no chair and also needed to stand to watch three other residents feeding themselves at another table while she was the only staff member present in the dining area. The DON stated she expected staff to sit when assisting residents during meals to promote dignity.
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