F0557

D

Failure to Treat Resident With Dignity and Respect During Medication Encounter

Longview, Texas Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s right to be treated with dignity and respect when a nurse used explicit language while exiting the resident’s room. The resident was an older female with diagnoses including UTI, Parkinsonism, polyneuropathy, muscle wasting and atrophy, and type II diabetes. Her quarterly MDS showed she was usually able to make herself understood and understand others, with a BIMS score of 10 indicating moderate cognitive impairment. She required moderate assistance with toileting, lower body dressing, and bathing, and her care plan identified potential for pain related to polyneuropathy with multiple monitoring and reporting interventions.

Evidence from an undated electronic monitoring video, reviewed on 3/23/2026, showed an LPN walking to the resident’s bedside with a small cup in her hand, attempting to hand the resident a medication cup, then turning away and exiting the room. As the nurse exited, she stated, “I don’t have to take this (explicit language),” after which the resident placed her hands on top of her head. In an interview, the resident reported that some staff treated her with dignity and respect, but that staff also screamed at her, told her to “knock it off,” and were rude to her. She stated she had depression, took medication for it, and had reported a staff member who treated her poorly, though she could not identify the nurse other than that she worked on a different hall. The resident said there were only a few nurses who made her feel that she was worth something.

The resident’s representative reported having a video from the resident’s electronic monitoring device from 12/12/2025 at 10:00 p.m. and stated she had reported the incident to a nurse and the previous administrator, describing the incident as abuse “in a sense” and more mental abuse because the resident needed care. In a telephone interview, the LPN involved stated that on 12/12/2025 the resident was complaining of nausea and felt she was going to get sick, and that while walking out of the room she said, “I am sick of this (explicit language).” The LPN claimed the statement was directed to a CNA and related to a previous conversation, declined to discuss the lead-up to the statement, and could not recall if she administered the resident’s medication. A CNA interviewed later said she had not heard anyone talking rudely to residents, recalled the LPN attempting to give the resident medications and then stating she did not know what was wrong because the resident would not take them, and noted there was no conversation outside the door before or after the LPN entered the room. The CNA mentioned the LPN wore an earpiece and could have been on the phone, and acknowledged that if a resident overheard something, they could think staff were talking to them.

Other staff interviews confirmed expectations that residents be treated with dignity and respect and that disrespectful interactions could negatively affect residents emotionally. An LPN stated she had been in-serviced on abuse, neglect, exploitation, dignity, and respect, and recognized that overheard statements could make a resident feel disliked and depressed. The ADON, who was not employed at the time of the incident, reported hearing about the video and that the facility had to report it, and stated that everyone was responsible for ensuring residents felt safe and were treated with dignity and respect. The administrator stated the LPN’s statement could be taken wrong and could be abuse, and that she expected staff to talk to residents in a manner that showed dignity and respect and to report any disrespect immediately. Review of the LPN’s personnel file showed she was hired on 8/14/2025 and terminated on 12/17/2025 for “Resident Interaction.” Review of grievance/complaint logs for December 2025 did not show a grievance related to this incident or other concerns about the LPN, and the facility’s policies on abuse prevention and resident rights required that residents be free from verbal and mental abuse and that employees treat all residents with kindness, respect, and dignity.