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F0550
D

Failure to Treat Resident with Dignity and Respect During Care

Commerce, Texas Survey Completed on 05-08-2025

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) failed to treat a resident with respect and dignity during care. The resident, an older female with Parkinsonism, anxiety disorder, and major depressive disorder, was cognitively intact and required significant assistance with daily activities. On the day of the incident, the CNA spoke to the resident in a loud manner and patted her hand while attempting to provide care, actions that were not consistent with maintaining a calm and respectful environment as outlined in the resident's care plan. Interviews revealed that the CNA admitted to tapping the resident's hand in response to the resident's physical and verbal aggression, and acknowledged making statements to residents that could be perceived as disrespectful or pressuring. A licensed vocational nurse (LVN) who witnessed the incident reported that the CNA raised her voice at the resident and had previously spoken to residents in a manner that was not dignified, including making demands and disregarding refusals of care. The LVN stated she had to intervene and had reported the CNA's behavior to management. Further interviews with facility leadership indicated that the director of nursing (DON) and administrator were not previously aware of the CNA's pattern of loud or disrespectful communication with residents. The facility's policy required all employees to treat residents with kindness, respect, and dignity, but the CNA's actions on the day in question did not align with these expectations. The incident was documented and investigated, with staff and leadership interviews confirming the failure to provide care in a manner that promoted the resident's dignity and quality of life.

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