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F0557
D

Failure to Maintain Resident Dignity During Incontinence Care

Monrovia, California Survey Completed on 09-17-2025

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

Certified Nursing Assistant (CNA) 1 failed to maintain the dignity of a resident who was dependent on staff for dressing and toileting hygiene. The resident, who had diagnoses including conversion disorder, aphonia, and general anxiety disorder, was admitted as incontinent of bowel and bladder and required to be checked for incontinence at least every two hours per the care plan. On the day in question, the resident experienced an episode of stool incontinence in the morning and requested to be changed by CNA 1 starting at 8 AM. CNA 1 did not respond to the request or check on the resident for over five hours, leaving the resident in a soiled diaper until 12:30 PM, when another CNA took over care and found the resident soiled. The resident communicated feelings of frustration and helplessness due to being left in a soiled state. The resident's roommate confirmed the presence of a foul stool odor in the room starting around 10 AM. CNA 1 admitted to not checking or changing the resident during the assigned shift and was unaware of the reason for the resident's distress. Facility policy required care to be provided in a manner that promotes resident well-being and dignity, including identifying and addressing individual needs and preferences through assessment.

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