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F0557
D

Failure to Obtain Resident Consent for Room Searches

Duluth, Minnesota Survey Completed on 04-17-2025

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

The facility failed to honor the rights of two residents to be treated with respect and dignity regarding their personal space and possessions. Specifically, one resident, who was her own responsible party and had intact cognition, was subjected to repeated room and personal property searches without her voluntary consent. Documentation showed that searches were conducted after visits from family or when the resident returned from a leave of absence, as per physician orders. The resident's care plan identified room searches as a trigger for behavioral issues, and progress notes detailed multiple instances where searches were performed, sometimes after the resident initially refused consent and only acquiesced after persistent staff requests. In some cases, searches were conducted while the resident was not present, including during a period when she was hospitalized. Interviews with staff, including an LPN, social services designee, RN, and the administrator, revealed inconsistent understanding and application of the facility's policy, which required reasonable suspicion, administrator approval, and documented verbal consent from the resident or representative before conducting searches. Staff acknowledged that consent was not always obtained voluntarily and that searches were sometimes justified by facility policy or physician orders rather than resident agreement. The facility's written policy emphasized the necessity of resident understanding and consent, which was not consistently followed in practice.

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