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F0550
D

Failure to Provide Dignified, Person-Centered Redirection for Resident with Dementia

Centennial, Colorado Survey Completed on 04-30-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a certified nurse aide (CNA) failed to honor a resident's right to a dignified existence and person-centered care. The resident, a 70-year-old individual with severe dementia, mood disturbances, and Parkinson's disease, was observed during a lunch meal service to have spilled a glass of clear liquid on the food preparation counter. The CNA approached the resident from behind and physically redirected her by placing both hands under her armpits and moving her away from the area, without providing any verbal explanation, reassurance, or calming interaction. This action was not in accordance with the resident's care plan, which specified the use of verbal redirection, allowing time for response, and other person-centered interventions tailored to her cognitive and communication impairments. The resident's care plans, which addressed her impaired communication and cognitive functioning, outlined interventions such as providing verbal and visual cues, explaining procedures, and using calm, simple language. Physical redirection was not included as an intervention. Staff interviews confirmed that the CNA did not follow the care plan and that the expected approach was to use verbal redirection or comforting objects. The incident demonstrated a failure to implement the individualized care plan interventions, resulting in the resident not experiencing a dignified and person-centered response during the incident.

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