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F0550
D

Failure to Ensure Residents' Right to Dignity and Respect

Saint Louis, Missouri Survey Completed on 05-01-2025

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

Two residents experienced derogatory and disrespectful remarks from staff members, in violation of their rights to dignity and respect. One resident, who had severe cognitive impairment and required substantial assistance with transfers, was involved in an incident where a CNA responded to the resident's distress during a transfer by saying, "we all have to go someday" after the resident asked, "are you trying to kill me?" This exchange was witnessed by a receptionist, who reported the CNA's rough handling and inappropriate comment. The resident's care plan did not document resident rights, and the resident later reported no memory of the incident. Another resident, who had no cognitive impairment and was dependent for transfers due to multiple medical conditions including a fractured hip and end stage renal disease, reported that a CNA was rough and rude during care. The resident described being pushed towards the bed during a transfer and being spoken to with profanity in the presence of a visitor. The resident felt disrespected by the staff member's attitude and reported the incident to the Administrator. The care plan for this resident also lacked documentation regarding resident rights. The facility's policy required all staff to be aware of and comply with resident rights, with annual in-services and prompt investigation of any violations. However, the Administrator confirmed that only the involved staff member was inserviced following the incidents, rather than all staff. Both incidents were documented as customer service events related to staff attitude and rough handling, and both residents' care plans failed to include documentation of resident rights.

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