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F0550
D

Failure to Maintain Resident Dignity During Perineal Care

George West, Texas Survey Completed on 04-16-2025

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 nurse aide (CNA) failed to treat a resident with dignity and respect during perineal care. The resident, an elderly female with Alzheimer's Disease and a severe cognitive impairment (BIMS score of 3), required assistance from two staff members for all activities of daily living (ADLs) due to her condition and history of being resistive or combative during care. Despite this, the CNA provided care alone and, during the process, wiped the resident's buttocks and showed her the soiled wipe with feces on it twice. The CNA also accidentally placed a blanket over the resident's face while repositioning it for care, which the resident immediately removed. The incident was witnessed by a family member, who reported the CNA's actions to facility leadership, describing the behavior as disrespectful and abusive. Surveillance video confirmed that the CNA intentionally held the dirty wipe in the resident's plain view on two occasions. Interviews with other staff members, including another CNA, an LVN, and the DON, confirmed that such actions were inappropriate and not in line with treating residents with dignity and respect. The facility's policy emphasized the importance of promoting and maintaining resident dignity during care. The resident's care plan specified the need for two staff members during care and encouraged resident participation in ADLs as tolerated. The CNA's actions, including providing care alone, showing the soiled wipe, and covering the resident's face with a blanket, were inconsistent with the care plan and facility policy. The resident was unable to respond to interview questions due to her cognitive impairment.

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