Untimely Call Light Response and Delayed Toileting Assistance Compromising Resident Dignity
Summary
The deficiency involves the facility’s failure to answer resident call lights in a timely manner, resulting in delayed toileting assistance and compromised dignity for multiple residents. Call light response logs for several days showed repeated response times ranging from approximately 13 to over 40 minutes, despite residents’ documented needs for prompt toileting due to incontinence, diuretic use, constipation, and mobility limitations. The facility did not have a call light policy or a defined maximum wait time, and staff interviews revealed varying expectations for response times, generally around five to seven minutes, which were not consistently met, especially during high-activity periods such as mornings and mealtimes. One resident with intact cognition, chronic constipation, mixed urinary incontinence, and limited shoulder mobility required substantial assistance with toileting and transfers and was on a bowel regimen. Her care plan and bowel/bladder assessment directed staff to offer toileting at specific times, including before and after meals and at bedtime. Call light logs showed numerous instances where her call light remained unanswered for 18 to over 40 minutes. She reported that after lunch she activated her call light for help to have a BM, was unable to wait long when she had the urge, and ultimately had to flag down a therapy staff member in the hallway because no one responded for what she described as over an hour. She described feeling miserable, surprised she could hold her bowels that long, and stated that long waits occurred at least weekly, more often on day shift, and that she had small urine accidents because she could not get to the bathroom in time. Another resident with intact cognition, morbid obesity, impaired mobility, and on diuretics required substantial assistance with toileting hygiene and transfers and used a urinal with staff help. Call light data showed multiple delays between roughly 13 and 20 minutes. During one observation, he had already activated his call light for help with the urinal and reported that in the past it had taken up to 30 minutes to get assistance, and that long waits had been occurring for some time. During the observed episode, staff did not arrive for approximately 15 minutes, by which time he had already become incontinent in his brief and expressed embarrassment and frustration. He stated he had discussed long call light waits with other residents while staff were present, but the wait times did not improve. A third resident with impaired vision, hip fracture, impaired mobility, and urinary incontinence used a wrist call light and required assistance with ambulation and transfers, including use of a stand lift with total assist of two. Her assessment noted she had to rush to the bathroom when she felt the urge to void. Call light logs documented at least one instance where her call light was not answered for more than 15 minutes. She reported that while most staff answered quickly, she had waited up to 20 minutes at times, during which the urine came too fast for her to reach the bathroom, leading to incontinence episodes that made her feel upset and embarrassed. She also commented on staff turnover and some staff being on their cell phones frequently. A fourth resident with dementia, impaired mobility, and on diuretics and other psychotropic medications was dependent for transfers and toileting and used a four-point lift. Her care plan and assessments indicated she was continent of bowel and bladder, used the call light, and could report when she needed to void. However, nursing assistant documentation showed at least two episodes of urinary incontinence, and call light logs revealed multiple delays between approximately 14 and 37 minutes. She reported waiting up to 25 minutes for assistance at times, nearly urinating in her pants, and feeling upset and angry when unable to get to the bathroom when needed. She stated that long waits occurred every couple of days, more often during mealtimes, and that while she had not yet become incontinent on some days, she was frustrated that she could not take herself to the bathroom. Staff interviews confirmed that the expectation was to answer call lights within about five to seven minutes, and staff acknowledged that this often did not occur, particularly during early mornings, mealtimes, and evening “rush to bed” periods. Multiple nursing assistants stated that long waits could lead to residents attempting self-transfers, falls, or incontinence, and that residents across the building had voiced concerns about long call light times. One assistant described residents in the dining room discussing their frustration and using the call light cancel and re-press function to make their calls appear more recent. Another assistant reported witnessing a resident fall after attempting to self-transfer with the call light on. The DON confirmed there was no written call light policy and no specific maximum wait time in facility policies, while facility resident rights and dignity policies required that residents be treated with dignity and that staff promptly respond to requests for toileting assistance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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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