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F0550
D

Failure to Ensure Dignified and Respectful Medication Administration

Coldwater, Michigan Survey Completed on 06-18-2025

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 resident with dementia and behavioral disturbances was subjected to undignified treatment during medication administration. According to facility documentation and staff interviews, a Licensed Practical Nurse (LPN) entered the resident's room to administer a new stomach pill that could not be crushed. The resident was lying flat in bed and repeatedly expressed an inability to swallow the pill, with water running out of his mouth onto his chest. Despite these difficulties, the LPN continued to insist that the resident swallow the pill and used vulgar language during the interaction. The resident verbally expressed distress, stating that the nurse was killing him. A Medical Assistant present in the room corroborated the resident's repeated statements of being unable to swallow the pill and reported the LPN's use of inappropriate language. The facility's investigation found that the resident had no recollection of the incident when later interviewed by a social worker. The LPN involved had received education on resident rights in the previous three years. The incident was reported after the resident's death, and the LPN was not available for interview during the investigation.

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