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F0550
D

Failure to Ensure Dignified and Respectful Transportation for Residents

Eagle Pass, Texas Survey Completed on 05-15-2025

Penalty

Fine: $21,645
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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

The facility failed to treat residents with respect and dignity by not providing appropriate transportation methods for medical appointments, as evidenced by the experiences of two cognitively intact female residents. One resident, who had a history of sepsis, pyogenic arthritis, COPD, and acute pyelonephritis, reported being transported in her wheelchair across a bumpy street to a doctor's office instead of being taken in the facility van. This method of transportation caused her significant knee pain, especially as she was scheduled to receive a knee injection at the appointment. There was no documentation in her medical record explaining why the van was not used for her transport. Another resident, with diagnoses including aftercare following joint replacement, overactive bladder, difficulty walking, anxiety disorder, and Type 2 Diabetes Mellitus, also reported being taken to a doctor's appointment in her wheelchair. She stated that the van driver told her it would be too much trouble to load her into the van for a short trip across the street. This resident expressed feeling embarrassed by being pushed in her wheelchair down the street and indicated she was not given a choice regarding her preferred method of transportation. Interviews with other residents and staff confirmed that transporting residents in wheelchairs across the street was a common practice, and that residents were not routinely asked for their preferences regarding transportation. The facility's policy required that residents be transported in a safe manner by a licensed driver, secured by seat belt in the vehicle, and assisted in and out of the vehicle by trained staff, but these procedures were not followed in the cases described.

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