Failure to Honor Resident Choice to Get Out of Bed After Therapy Discharge
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to self-determination and choice regarding daily routines, specifically the resident’s request to get out of bed and into a wheelchair. On 12/2/2025 at 11:15 a.m., Resident 18 reported that she asked every day to be placed in her wheelchair, but CNAs told her they would return and did not come back until later, and that she had not been out of bed since her therapy was discontinued a couple of weeks prior. A CNA stated at 11:20 a.m. that she had assisted the resident out of bed when the resident was in therapy, but it had been weeks since she last assisted the resident to her wheelchair and she believed the resident was no longer in therapy. An LPN stated at 11:25 a.m. that the resident should be out of bed as requested by the resident or according to a schedule for being up in a chair. On 12/3/2025 at 1:00 p.m., the Rehab Director confirmed that the resident had no bed restrictions and could be out of bed as requested by the resident or per a schedule, and that the resident received PROM (passive range of motion) to all extremities. Earlier that day at 10:30 a.m., the DON stated that all residents should be out of bed per a schedule, therapy, or resident request, and that no one should remain in bed solely because therapy was completed. Record review showed that the resident had diagnoses of hemiplegia and hemiparesis and a history of falling, with orders dated 4/22/2025 for nursing rehab transfer to a manual wheelchair via full body lift with 2–3 staff for safety, and a care plan dated 1/25/2025 specifying transfer via mechanical aid, lift sling, and 2 staff for transfers. An occupational therapy discharge summary indicated the highest practical level had been achieved. Despite these orders and the facility’s written policy on resident rights and self-determination, the resident’s expressed choice to get out of bed and into a wheelchair was not being consistently honored after therapy was discontinued.
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