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F0552
E

Failure to Inform Residents of Therapy Procedures Leads to Discomfort

Butler, Missouri Survey Completed on 04-29-2025

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

Contracted Physical Therapy Assistant (PTA) A failed to adhere to residents' rights by not adequately informing residents about the care and treatments being provided prior to initiating therapy sessions. Multiple residents reported that PTA A did not explain the procedures or the reasons for physical contact during therapy, such as muscle palpation or massage-like actions. This lack of communication led to confusion and discomfort among several residents, some of whom were unfamiliar with therapy or had not previously received such treatments from PTA A. The deficiency involved seven residents, most of whom were cognitively intact and had various medical conditions including post-surgical weakness, stroke, muscle wasting, and spondylosis. Residents described instances where PTA A entered their rooms, began therapy or massage-like activities without prior explanation, and in some cases, touched areas near the chest or abdomen. While no residents reported pain or physical injury, several expressed feeling uncomfortable, nervous, or "creepy" after the interactions. Some residents did not immediately report the incidents, only disclosing their discomfort when later questioned by facility staff. Interviews with facility staff and the contract therapy agency director confirmed that proper protocol required PTA A to explain all procedures and obtain informed consent before touching residents, especially in sensitive areas. The director acknowledged that certain therapy techniques might require contact with the chest or inner thigh, but emphasized the necessity of clear communication to prevent misunderstanding. The lack of explanation and failure to ensure residents understood the nature of the therapy led to the deficiency, as residents' rights to be informed and to refuse care were not upheld.

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