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F0558
D

Failure to Accommodate Resident's Request for Tray Removal

Plano, Texas Survey Completed on 11-20-2025

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

A deficiency occurred when a certified nursing assistant (CNA) failed to accommodate a resident's request to remove a lunch tray from his bedside table, which impeded his ability to access his iPad. The resident, an elderly male with severe cognitive impairment (BIMS score of 5) and significant functional limitations in both upper and lower extremities, required setup or clean-up assistance with eating. During the incident, the CNA was attending to the resident's colostomy bag and, when asked to remove the tray, delayed the action, stating her hands were dirty and she intended to remove it after finishing her task. The resident reported that the aide refused to remove the tray even after completing the colostomy care, and this interaction was inadvertently recorded and reported by a family member. Interviews with facility staff confirmed the sequence of events. The CNA acknowledged delaying the removal of the tray and expressed a misunderstanding, believing the resident wanted the tray removed from the room rather than just off the table. A licensed vocational nurse (LVN) present in the room at the time was focused on disconnecting the resident's IV and did not notice the request or the conversation between the resident and the CNA. The administrator confirmed that the incident was identified as a customer service issue and unprofessional conduct, based on the review of the recording and staff interviews. The facility's policy on resident rights, as reviewed in the report, guarantees residents the right to a dignified existence and to be treated with respect, kindness, and dignity. The failure to promptly accommodate the resident's reasonable request for tray removal constituted a violation of these rights, as the resident was unable to access his personal items and exercise self-determination in his environment.

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