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F0561
D

Failure to Honor Resident's Right to Choose Bedtime

Philadelphia, Pennsylvania Survey Completed on 06-27-2025

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 was identified when staff failed to honor a resident's right to self-determination regarding their bedtime. The resident, who had diagnoses including adjustment disorder with depressed mood, anxiety disorder, gait and mobility abnormalities, muscle weakness, abnormal posture, and a history of falls, required extensive assistance from two or more staff for transfers. On the date in question, the resident reported that two staff members attempted to put them to bed before they were ready. Despite the resident's refusal, a nurse instructed the staff to proceed, and the resident was physically transferred to bed against their wishes. The following day, the resident was found to have bruising on both upper arms, which was brought to the attention of nursing staff by the resident's family. The resident also reported soreness in the right upper extremity. An internal investigation confirmed that the resident's rights were violated when staff transferred the resident to bed without consent, although it could not be determined if the bruising was directly caused by the incident.

Plan Of Correction

F 0561 Staff will be educated regarding residents' rights and self-determination. Residents will be educated at resident council regarding their rights and how to file a grievance if they feel their rights have been violated. The resident welcome book has been updated to include information regarding grievances and the grievance officer and will be distributed to all new and current residents.

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