Resident’s Right to Dignity and Freedom of Movement Not Respected
Penalty
Summary
A resident with Alzheimer's disease and a severe cognitive impairment, evidenced by a BIMS score of five on a recent quarterly MDS assessment, was observed self-propelling in a wheelchair near the nurses' station while verbalizing the need to use the bathroom. As the resident moved toward A Hall, a CNA approached from behind, stopped the wheelchair, and attempted to redirect the resident in another direction. The resident pointed down the hall and stated she wanted to go that way, but the CNA told her she did not need to go down there. The resident's tone elevated, and she began hitting the arm of her wheelchair while repeatedly stating she wanted to go toward A Hall. The CNA then grabbed the wheelchair handles, backed the resident up against the wall across from the nurses' station, and locked the wheelchair wheels to prevent her from moving down the hall or entering other residents' rooms. The resident's care plan, dated 10/27/2025, included goals to maintain her dignity and autonomy at the highest level, with interventions such as respecting her wishes and working with nursing staff to provide maximum comfort. The DON confirmed that restricting a resident's movement throughout the facility is against residents' rights and choices, and the Administrator stated that residents have the right to wander anywhere in the building, noting that residents are kept lined up in front of the nurses' station for more supervision. The facility's Resident Rights policy stated that each resident has the right to be treated with dignity and respect and that staff must honor and value each resident's input.
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