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F0550
D

Failure to Treat Resident with Dignity During Activity

Bad Axe, Michigan Survey Completed on 07-01-2025

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 staff failed to follow the care plan and treat a resident with dignity during and after a group activity. The resident, who had diagnoses including dementia, stroke, and behavioral disturbances, was observed to have severely impaired cognition and required assistance with activities of daily living. The care plan specified that staff should provide activities the resident enjoys, avoid interrupting her during activities, and offer reassurance, as she becomes confused and frustrated if contradicted. During a bingo activity, the resident became upset, insisting that her bingo chips, purse, and coat had been taken. Staff statements and video surveillance confirmed that a CNA argued with the resident, removed bingo chips from her hands, and forcefully pushed her in her wheelchair out of the activity room. The CNA was observed raising her voice, physically moving the resident's hands from the table, and quickly pushing her out of the room, despite offers of assistance from other staff. The incident resulted in the resident displaying distress, calling out, and slamming her hand on the table. Multiple staff interviews corroborated that the CNA's actions were loud, forceful, and did not align with the resident's care plan, which emphasized dignity and individualized support. The resident was later found in another area, still expressing confusion and distress about her belongings. Documentation in the medical record noted previous behavioral issues during activities, but the care plan required staff to manage these behaviors with patience and reassurance, which was not observed during this incident.

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