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F0550
D

Failure to Provide Privacy During G-Tube Care

Covina, California Survey Completed on 04-19-2025

Penalty

Fine: $54,900
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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

Staff failed to provide privacy for a resident during a G-tube site check. The Director of Staff Development (DSD) entered the resident's room, pulled up the resident's gown, and checked the G-tube site without closing the privacy curtain. This resulted in the resident's abdominal area and lower extremities being exposed to the roommate and potentially to the hallway. The DSD acknowledged during an interview that the privacy curtain was not closed and stated that it should have been used during activities of daily living (ADLs) to provide privacy. The resident involved had a history of dysphagia and required a G-tube for feeding, with orders for Jevity 1.2 to be administered via enteral pump. The resident was dependent on staff for all ADLs and had moderately impaired cognition. The care plan and facility policy both indicated that staff should maintain resident privacy and dignity during care and treatment procedures, including ensuring bodily privacy. The Director of Nursing (DON) also confirmed that privacy curtains should be closed during care to maintain dignity and privacy.

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