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F0550
D

Failure to Honor Resident Refusal During Incontinence Care

Commerce, Michigan Survey Completed on 07-23-2025

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, who was cognitively intact and dependent on staff for toileting, reported that a nurse aide checked their incontinence brief despite the resident's explicit refusal. The resident stated that their brief was dry and that they did not want to be checked or changed at that time. The nurse aide confirmed that, although the resident declined, they proceeded to check the brief, citing facility training and standard practice to check every resident's brief every two hours. This action was taken even though the resident was able to communicate their wishes clearly and had no behavioral issues. The resident's care plan included interventions to honor their preferences and encourage participation in decision-making. Facility policy also emphasized the importance of respecting resident rights, including dignity and the right to participate in care decisions. The incident was observed and confirmed through interviews and record review, demonstrating a failure to provide dignified care and to respect the resident's right to self-determination.

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