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F0583
D

Failure to Provide Privacy During Incontinence Care

Pasadena, Texas Survey Completed on 08-25-2025

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 certified nursing assistant (CNA) failed to provide adequate privacy during incontinence care for a male resident with a history of atherosclerotic heart disease, cognitive communication deficit, lack of coordination, muscle weakness, and impairments in both upper and lower extremities. The resident required substantial assistance with all activities of daily living and was incontinent of bowel and bladder. During the provision of incontinence care, the CNA did not draw the privacy curtain, resulting in the resident's naked buttocks being visible through the window to a surveyor passing by. The CNA stated that the privacy curtain was stuck and admitted she should have tried harder to pull it around before proceeding with care. The resident, who was cognitively intact, was unaware of his exposure during the incident and reported that the CNA typically pulled the privacy curtain during care. Facility policy required staff to provide privacy by pulling the curtain or closing the door during personal care, and the administrator confirmed that this was the expected practice. The failure to ensure privacy during personal care was observed directly by the surveyor and was inconsistent with both facility policy and staff training.

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