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F0550
E

Failure to Maintain Resident Dignity During Meal Assistance

El Paso, Texas Survey Completed on 09-09-2025

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 treat several residents with respect and dignity during meal assistance, as evidenced by staff not sitting at eye level while assisting with feeding and not offering residents a choice regarding the use of clothing protectors. Observations revealed that multiple staff members, including a student CNA and CNAs, assisted residents with eating while standing, rather than sitting at eye level as required by facility policy and staff training. This practice was observed with at least three residents who had varying degrees of cognitive impairment and required different levels of assistance with eating. Staff interviews confirmed that they were aware of the expectation to sit while assisting with feeding, but some staff cited physical limitations or personal preference as reasons for not following this protocol. Additionally, the facility failed to ensure that residents were asked if they wanted to wear a clothing protector before it was placed on them. One resident reported not being asked and feeling unable to refuse once the protector was already on. Staff interviews indicated that it was common practice for some staff to put clothing protectors on residents without asking, despite being trained to offer residents a choice. The facility's policy and staff training emphasized the importance of promoting resident dignity and self-determination by offering choices and engaging residents in their care. The residents involved had significant medical histories, including dementia, diabetes, impaired mobility, and cognitive communication deficits, which made them dependent on staff for assistance with eating and other activities of daily living. The failure to follow established protocols for meal assistance and resident choice was confirmed through direct observation, staff and resident interviews, and review of facility policies and care plans. These actions and inactions resulted in a failure to maintain an environment that promotes or enhances residents' quality of life and dignity.

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