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F0550
D

Resident Exposed During Post-Shower Transfer, Violating Dignity and Privacy

South Pasadena, California Survey Completed on 04-23-2025

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

The facility failed to maintain a resident's dignity and privacy during post-shower care. Observation revealed that a certified nursing assistant (CNA) took a resident out of the shower room with only a gown covering the front of the resident's body, leaving both sides and the back exposed. The CNA acknowledged that the resident should have been fully covered during the transfer from the shower room to the resident's room. The Director of Nursing (DON) confirmed that the resident should have been covered with a poncho that would shield the entire body and shower chair for dignity. The resident, who was cognitively independent but required substantial assistance with bathing and dressing due to muscle weakness and diabetes mellitus, reported feeling disrespected and stated that a blanket should have been used for coverage. A review of the facility's policy on resident dignity and personal privacy indicated that residents should be shielded during all personal care and treatment procedures, and should be appropriately draped and dressed to avoid exposure and embarrassment. The policy specifically required covering residents during transfers to the shower or toilet. The failure to follow these procedures resulted in the resident being exposed during transfer, in violation of the resident's right to privacy and dignity.

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