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F0557
D

Failure to Ensure Resident Dignity During Incontinence Care

York, Pennsylvania Survey Completed on 09-05-2025

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

The facility failed to ensure that a resident was treated with respect and dignity during the provision of incontinence care. The resident, who had diagnoses including dementia with behavioral disturbance and adult failure to thrive, was assessed as having moderately impaired cognitive status and a history of verbally abusive behaviors related to dementia. During an incident, a nurse aide entered the resident's room to provide care, and the resident became combative, scratching and hitting the staff member. Another nurse aide entered the room and observed the first aide with her hand raised above her head as if to strike the resident, though the aide lowered her hand when the second aide entered. The resident verbally challenged the aide, saying "go ahead and hit me." The event was immediately reported to administration, and the resident was assessed with no new skin issues identified. The facility's policy required that residents be treated with dignity and respect at all times, including maintaining and enhancing self-esteem and self-worth. Staff interviews and written statements confirmed that the aide's actions, specifically raising her hand in a threatening manner, did not align with the policy of treating residents with dignity. The resident was unable to be interviewed due to cognitive deficits, but the incident was corroborated by staff statements and facility documentation. The Director of Nursing and Nursing Home Administrator acknowledged that the aide should have left the room and reapproached the resident later, rather than escalating the situation.

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