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F0550
D

Failure to Maintain Resident Dignity During Smoking Incident

Elk Horn, Iowa Survey Completed on 12-15-2025

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 nurse failed to provide dignity and respect to a resident during an incident involving smoking outside the facility. The resident, who had no cognitive impairment as indicated by a BIMS score of 15, requested to be taken outside to smoke. Staff members, including CNAs, assisted the resident outside, which led to a confrontation with an LPN. The LPN went outside and yelled at the resident and the staff, telling them that staff were not allowed to take residents outside to smoke. The resident reported feeling upset and stated that the nurse did not treat her with dignity or respect during the incident. The resident also expressed feeling bad for being the reason staff were yelled at and noted that some staff treated her well while others did not. Interviews with staff revealed confusion and inconsistency regarding the facility's smoking policy. Staff A, a CNA, stated that she was written up for taking the resident outside but the write-up was later destroyed due to conflicting policies. Staff B, another CNA, confirmed the incident and described the LPN as using a stern and unfriendly tone, which upset the resident. Both CNAs indicated uncertainty about the rules for staff assisting residents with smoking and whether the sidewalk was considered facility property. The LPN involved admitted to being loud and stern but denied yelling at the resident, stating her intent was to enforce facility rules. Administrative staff, including the DON and Administrator, provided conflicting information about the smoking policy and property boundaries. The DON stated that staff were not to take residents outside to smoke, but acknowledged this was not specified in the written policy. The Administrator confirmed that the sidewalk was not facility property and that only non-employee friends or family could assist the resident with smoking outside. There was no formal written investigation or documentation of the incident, and the DON did not speak directly to the resident about the event. The facility's policy on resident dignity emphasized maintaining respect and self-worth, but the actions during this incident did not align with those standards.

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