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F0550
D

Failure to Honor Resident's Right to Family Presence and Communication During Care

Sacramento, California Survey Completed on 07-22-2025

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 resident's request to have a family representative present during direct care was not acknowledged or honored by a Certified Nurse Assistant (CNA). The resident, who was admitted with Type 2 Diabetes Mellitus and had a language barrier, was assessed as cognitively intact. The care plan noted the resident spoke Spanish and had communication needs, but the communication device option was not checked. During an observation, the CNA did not allow the family representative or surveyor to observe care, despite repeated requests and the resident's language barrier. The CNA relied on gestures and a communication board for communication and did not ask the resident if she wanted her family representative present during care. The resident was observed to be visibly distressed, shaking, grimacing, and expressed fear of the CNA, stating a preference for an interpreter or family representative to be present during care. The family representative reported that the resident was now afraid to receive wound care due to inadequate communication and rough handling. Interviews with facility staff confirmed that family members are generally allowed to participate in care with the resident's permission, especially to assist with translation, but in this instance, the CNA did not follow this practice and did not consult the resident about her preferences.

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