F0550

D

Failure to Honor Resident’s Refusal of Bed Change and Mishandling of Personal Belongings

Milwaukee, Wisconsin Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor a cognitively intact resident’s rights to dignity, self-determination, and respect for her personal belongings during a facility-wide bed replacement. The resident, who has progressive multiple sclerosis, hypertension, and glaucoma, had a BIMS score of 15 indicating she was cognitively intact. When approached about changing her bed as part of a project to replace older beds, she explicitly refused, but her bed was nonetheless changed on 11/25/25 after facility staff and a corporate representative insisted that all beds had to be replaced. The Chaplain and DON were present when the bed and mattress were changed, and the Chaplain confirmed that the resident did not want her bed changed but it was done because beds throughout the facility were being replaced.

Following the bed change, the resident repeatedly complained to multiple staff that the new bed was causing significant back and hip pain, stating she could feel the bars in her back and could not stand up. She reported these concerns to nurses, the Chaplain, and the NP. Progress notes document her complaints of increased pain in the right hip and lumbar area and a request for an x-ray, which was obtained and reviewed. Review of the MARs showed that prior to the new bed, her pain scores were consistently 0 with very limited PRN Norco use, but during the period she had the new bed, there was a marked increase in documented pain scores and frequent administration of PRN Norco 5/325 mg for breakthrough pain. The social worker later documented that the resident reported the new bed was causing back pain and that she preferred the older model and wanted it switched back.

When the facility eventually agreed to switch the resident back to an older bed and mattress on 12/18/25, the process of moving her belongings was not handled in accordance with her care plan and rights. The resident had a care plan problem related to hoarding and a history of displacement, with an explicit approach to avoid removing items from her room without her participation. Despite this, the interim social worker and housekeeping staff moved multiple personal items from the bed, under and around the bed, and placed them in the hallway, and housekeeping then took some of these belongings to the garbage chute room as part of an effort to “clean” the room, without asking the resident which items could be discarded. The resident, who typically did not leave her room, came into the hallway visibly upset when she realized items were missing. Housekeeping acknowledged placing the resident’s belongings in the garbage chute room and then retrieving them after the resident became upset, but the resident reported that not all items were returned, including a bag with snacks she valued. The facility’s own resident rights policy states that residents are entitled to exercise their personal rights to the fullest extent possible and to always be treated with respect, kindness, and dignity, which was not followed in this situation.