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F0557
D

Failure to Honor Resident Dignity During Care

Livingston, Texas Survey Completed on 05-21-2025

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) repeatedly put her fingers in the face of a female resident with Alzheimer's disease, cerebral infarction, anxiety disorder, dysphagia, and schizophrenia. The resident was rarely understood, usually understood others, and required moderate to total assistance with daily care. The incident was captured on video by a family member, who later reported feeling disturbed after viewing the footage. The video showed the CNA placing her fingers in the resident's face multiple times while preparing to provide incontinent care, which visibly agitated the resident and led her to attempt to bite the CNA's fingers. Interviews with facility staff, including the Interim Director of Nursing (DON), the Regional Director of Clinical Services, and other nursing staff, confirmed that the CNA's actions were inappropriate and could affect the resident's dignity. The CNA herself admitted to being playful with the resident at the time, but later recognized her behavior as inappropriate, especially after learning of the resident's dementia diagnosis. Staff members interviewed agreed that putting fingers in a resident's face was not acceptable and could impact a resident's sense of dignity. The facility's policy on resident rights, revised in December 2016, requires all employees to treat residents with kindness, respect, and dignity, in accordance with federal and state laws. The actions of the CNA were found to be inconsistent with this policy, as confirmed by both facility leadership and direct care staff after reviewing the video evidence and discussing the incident.

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