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F0849
D

Failure to Ensure Resident Dignity and Professional Conduct During Hospice Care

San Rafael, California Survey Completed on 08-21-2025

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 hospice registered nurse (HRN) failed to maintain a resident's dignity and privacy during care. The resident, who had a dislocated internal left hip prosthesis and Huntington's disease, was left exposed from the waist down and visible to the public for approximately 22 minutes while waiting for a wound change. The HRN was present in the room but did not begin the procedure, and the Director of Nursing (DON) confirmed the resident remained unclothed during this period, which was not in accordance with the facility's policy on accommodating resident needs and maintaining dignity. Additionally, the HRN displayed unprofessional conduct by crying and yelling unprovoked in the resident's room, causing the resident to appear confused and scared. The DON intervened and asked the HRN to leave the room, later confirming that the HRN's behavior was unprofessional and made the resident feel scared. The facility's policies and hospice contract require contracted hospice providers to meet professional standards and ensure resident dignity, which was not upheld in these instances.

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