Failure to Respect Resident’s Personal Possessions and Dignity
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to be treated with respect and dignity and to retain and use personal possessions. The facility’s policy on Resident Rights and Responsibilities, revised January 2024, requires employees to treat all residents with kindness, respect, and dignity. Resident #1, admitted in August 2023, had diagnoses including moderate vascular dementia with mood disturbance and an anxiety disorder. A Quarterly MDS dated 09/30/25 documented moderate cognitive impairment with a BIMS score of 9/15. The resident’s Mood and Behavioral Care Plan, reviewed 12/03/25, noted vascular dementia with mood disturbance and agitation, with a history of hitting, kicking, grabbing, spitting, screaming, or threatening others, and identified interventions such as assessing triggers for aggression or agitation and providing de-escalation strategies including a quiet environment and reassurance. On 12/20/25, an altercation occurred between Certified Nurse Aide (CNA) #1 and Resident #1 at the nurses’ station. According to the facility’s investigation report and staff interviews, Nurse #1 was on the phone addressing a medical emergency while Resident #1 sat in a wheelchair at the nurses’ station, with CNA #1 and CNA #2 nearby. CNA #2 leaned forward to speak with the resident and briefly touched the top of the resident’s hat. Resident #1 immediately yelled and verbally objected, stating that the hat should not be touched, and CNA #2 stopped touching the hat after the objection. Despite having witnessed this objection, CNA #1 then approached and touched the resident’s hat. Nurse #1 and CNA #2 reported that Resident #1 loudly objected to CNA #1 touching the hat, demanded that CNA #1 stop, and that CNA #1 nevertheless touched the hat a second time. Nurse #1 stated that after the second touch, the resident’s agitation escalated, leading him to separate CNA #1 from the resident. When Nurse #1 returned to the nurses’ station area about 15 minutes later, Resident #1 remained very agitated, cursing and kicking a medication cart. CNA #1 acknowledged in a telephone interview that she touched the resident’s hat despite having seen the resident loudly object to CNA #2 doing so. The Director of Social Services later observed that the resident was “a bit revved up,” consistent with behavioral presentations that occurred at times for this resident, and the DON confirmed that CNA #1 had teased and provoked the resident by touching the hat despite the resident’s objections.
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