F0550

D

Resident Fed in Dining Room With Fecal Matter on Hands, Violating Dignity and Hygiene

Austin, Texas Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was clean and treated with dignity while being assisted with feeding in the dining room. The resident was an older male with moderate cognitive impairment, dementia, visual loss including left eye blindness, generalized weakness, poor endurance, impaired balance, and reduced range of motion in both shoulders. His MDS and care plan documented that he required substantial to maximal assistance with eating and personal hygiene, and that he needed maximum assistance for ADLs and mobility. The care plan also included an intervention to ensure the resident was clean, dry, and comfortable before mealtime and to provide assistance as needed for meal completion.

On the evening in question, the resident’s family member arrived during dinner and went to the dining room, where the resident was being assisted with his meal. As the family member approached the table, he smelled a foul odor like bowel movement and then observed fecal matter on both of the resident’s hands, which were at chest level. The family member became extremely upset and demanded that the resident be cleaned. The social worker, who was present in the facility, went to the dining room and also observed fecal matter on both of the resident’s hands while the resident was being fed by a CNA. The social worker stated he was shocked and alarmed by what he saw and noted that the resident was known to scratch himself and put his hands in his pants.

The CNA who was feeding the resident reported that he had not assisted the resident to the dining room and was unsure who had done so. He stated that after passing out meal trays, he sat down to assist the resident with feeding and had been feeding him for approximately 10 minutes before the family member arrived and alerted him to the fecal matter on the resident’s hands. The CNA stated he had not noticed the fecal matter because the resident did not use his hands during feeding and that he did not smell it, believing it had dried. A LVN in the dining room became aware of the situation when he heard the family member and saw the resident being fed with fecal matter on his hands. Both the CNA and LVN acknowledged that residents were expected to be groomed and cleaned prior to going to the dining room. Facility leadership, including the DON and administrator, confirmed that the resident had known behaviors of putting his hands in his briefs and that it was their expectation that residents be clean when fed. The facility’s resident rights policy stated that employees shall treat all residents with kindness, respect, and dignity, and that residents have the right to a dignified existence and to be treated with respect, kindness, and dignity.

Interviews indicated that the resident himself did not recall the event when interviewed later. The social worker stated that at the time of the incident the resident was calm, did not recognize he had fecal matter on his hands, and only responded to the family member’s upset reaction by asking why he was upset. The CNA reported that the resident told the family member to “shut up,” which the CNA believed was due to embarrassment. The social worker acknowledged that he did not complete a psychosocial evaluation related to the incident and stated that he "dropped the ball" in not asking psychosocial questions within 72 hours. The DON and administrator both acknowledged awareness of the incident and described it as an unfortunate situation involving infection control and dignity issues, occurring despite the resident’s known behavior of putting his hands in his pants and the care-planned need for assistance with personal hygiene and to ensure cleanliness before meals.