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F0550
D

Resident's Hearing Device Removed During Agitation Incident

Dubuque, Iowa Survey Completed on 09-02-2025

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 with legal blindness, hearing impairment requiring a cochlear implant, depressive disorder, and anxiety was dependent on staff for set-up assistance with eating and transfers, and used a wheelchair for mobility. The resident's care plan indicated a need for the cochlear processor to be in place with charged batteries during times of agitation and communication difficulty, as the device was essential for hearing. The care plan also instructed staff to monitor the resident's eating, encourage slow eating, and alternate liquids and solids. During a mealtime, the resident became verbally agitated and exhibited unsafe eating behaviors, such as cramming food into his mouth. Staff attempted to manage the situation by cutting up the resident's food and providing verbal cues to slow down, which further upset the resident. Staff A, a CNA, became frustrated with the resident's behavior and, while transporting the resident out of the dining room, removed the resident's cochlear processor, leaving the resident unable to hear. Staff A kept the processor in his pocket and only replaced it after less than a minute, once inside the elevator. This action was observed by another staff member and reported to nurse management. Interviews with staff and the resident confirmed that the removal of the cochlear processor occurred during the incident, and the resident recalled similar actions by the same staff member during other care activities. The facility's policy states that all residents have the right to be free from acts of personal degradation and involuntary seclusion, and the removal of the hearing device deprived the resident of the ability to communicate and participate in his environment, violating his right to dignity and respect.

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