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F0550
D

Failure to Maintain Resident Dignity and Proper Feeding Technique

Fort Worth, Texas Survey Completed on 07-17-2025

Penalty

Fine: $185,385
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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 certified nursing assistant (CNA) was observed feeding a female resident with multiple medical conditions, including mild cognitive impairment, psychotic disturbance, difficulty walking, and chronic illnesses such as diabetes and chronic kidney disease. During the observation, the CNA stood over the resident while feeding her tamales with chili cheese, placing the fork in her mouth from a standing position. The CNA acknowledged in an interview that he does not typically stand while feeding residents and explained that someone was in his way at the time. He also recognized that feeding a resident while standing could increase the risk of choking. Interviews with the Assistant Director of Nursing (ADON) and the Administrator confirmed that staff are expected to sit and engage with residents during feeding, and that standing over a resident may make them feel rushed or uncomfortable, and prevents the aide and resident from being at eye level. The facility was unable to provide a specific policy for feeding residents when requested, instead submitting a policy for assistive feeding devices. This failure to ensure proper feeding technique and environment did not promote the resident's dignity or quality of life, as required.

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