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F0550
D

Resident Transported in Wheelchair Without Regard for Dignity

New Bern, North Carolina Survey Completed on 09-18-2025

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 deficiency occurred when a resident, who was severely cognitively impaired, was transported in a geriatric wheelchair by an occupational therapist (OT) in a manner that did not honor the resident's right to dignity. The OT pulled the wheelchair from behind, positioning the resident so that he was unable to see where he was being taken. This action was observed by surveyors and was confirmed during interviews with the OT, who stated she was unaware that this method of transport was a dignity issue and explained she pulled the chair because it was difficult to push. The resident had an active order for occupational therapy evaluation and treatment. The incident was witnessed during a routine observation, and the OT involved was an agency staff member who had received facility training on treating residents with dignity and respect. The Rehabilitation Manager and the DON both acknowledged that staff should have known this method of transport was inappropriate and a concern for resident dignity.

An unhandled error has occurred. Reload 🗙