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F0557
D

Failure to Provide Timely and Respectful Care to Resident

South Gate, California Survey Completed on 04-14-2025

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 certified nursing assistant (CNA) failed to provide timely and respectful care to a resident who required substantial assistance with toileting hygiene, bathing, and bed mobility due to a left hip fracture, history of falls, lack of coordination, and urinary retention. The resident, who had moderately impaired cognitive skills, pressed the call light during the night shift to request assistance with being changed after becoming soiled. The CNA entered the room, looked at the resident, and left without providing care. When the resident pressed the call light again, the CNA returned, aggressively pulled the call light away, instructed the resident not to use it, and did not provide the requested care. The resident was eventually changed by staff on the following shift. The resident expressed feelings of anger towards the CNA and described the CNA's actions as aggressive and disrespectful, including separating the resident's legs forcefully and fanning the soiled brief in a manner that suggested disgust. Interviews with other CNAs and the Director of Staff Development (DSD) revealed a pattern of similar behavior by the same CNA, including previous disciplinary actions for not changing residents and leaving them soiled. Other staff reported that the CNA often failed to complete assigned tasks and was not a team player, leading to delays in resident care. Facility policies reviewed indicated that staff are required to promote dignity, respect, and timely response to resident needs, including responding to call lights and providing explanations if care is delayed. The Director of Nursing (DON) confirmed that the CNA's actions did not align with facility expectations for resident dignity and timely care. The failure to provide prompt and respectful assistance, as well as the manner in which the resident was treated, constituted a lack of respect and dignity for the resident.

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