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F0550
D

Failure to Protect Resident Dignity Due to Inappropriate Staff Behavior

Novato, California Survey Completed on 05-01-2025

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 licensed nurse (LN C) repeatedly pinched a resident (Resident 2) in a teasing manner, despite the resident's clear and repeated requests for the behavior to stop. Resident 2 reported that the pinching was painful, disrespectful, and violated her dignity. She distinguished between necessary pinching during injections and the inappropriate, playful pinching by LN C, which occurred even when not administering care. Resident 2 stated she informed multiple staff members about the unwanted behavior, but her concerns were dismissed or minimized, with staff suggesting LN C was just being playful or not believing her reports. This lack of response from staff left Resident 2 feeling hurt, frustrated, and disrespected. Another resident (Resident 4) also reported being pinched by LN C, specifically on the cheeks, and indicated that she had communicated her discomfort to LN C. Staff interviews confirmed awareness of LN C's immature and playful behavior, including the pinching of residents. The Director of Staff Development acknowledged prior in-servicing of LN C for issues related to conduct and professionalism and was not surprised by the recurrence of such behavior. Facility policy reviewed indicated that patients have the right to be treated with consideration, respect, and full recognition of dignity and individuality, which was not upheld in this instance.

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