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F0557
G

Failure to Maintain Resident Dignity and Privacy During Rectal Medication Administration

Clearlake, California Survey Completed on 10-07-2025

Penalty

Fine: $61,705
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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 registered nurse (RN) failed to provide nursing care in a manner that maintained a resident's dignity and respect during the administration of a rectal suppository. The RN did not stop the procedure when the resident complained of pain and requested that the procedure be stopped. Instead, the RN continued to move her finger inside the resident's rectum for several minutes, stating it was necessary for the medication to dissolve, despite the resident's clear expression of discomfort and request to cease. Additionally, the RN did not ensure the resident's privacy during the procedure. The privacy curtain was not drawn, and the door to the hallway was left open, allowing others to see the resident partially unclothed from the waist down. This lack of privacy was confirmed by both certified nursing assistants (CNAs) present during or after the incident, with one CNA noting that the resident's buttocks were visible from the hallway. The RN also failed to adequately explain the procedure to the resident prior to performing the invasive rectal medication insertion. The facility's policy required staff to explain procedures, provide privacy, and respect residents' rights to refuse or discontinue treatment. The resident, who had intact cognitive skills and a history of depression but no other psychiatric diagnoses, reported feeling violated, embarrassed, and traumatized by the incident. The event resulted in the resident experiencing pain, anxiety, and ongoing psychological distress.

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