Other·February 28, 2022

§483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion The facility failed to protect one resident (Resident 1) from abuse, when CNA (Certified Nursing Assistant) B grabbed her vaginal area, forcefully, through her brief. This failure caused Resident 1 to cry and experience sadness when she felt physically and emotionally violated. A Review of Resident 1's medical record and MDS report (an assessment the facility does upon admission and change of condition) indicated Resident 1 was admitted on 3/30/21, with diagnoses including: Aftercare following surgery and Malignant Neoplasm of Parietal Lobe (a brain tumor). She had no loss of memory, problem solving, or language skills. During an interview with the Administrator on 7/12/21 at 9 am, he stated CNA A came to him the morning of 4/27/21, and reported, when she was showering Resident 1 that morning, Resident 1 asked CNA A, "Can I talk to you? I can't talk to anyone." Resident 1 then began to cry and stated she had been abused by CNA B the night before. Resident 1 stated, when CNA B came into her room, CNA B was laughing in a mocking way, came to her bed and loudly said, "What language do you speak?" CNA B then very gruffly told Resident 1 to let her check Resident 1's brief to see if she was wet. CNA B was pushing Resident 1 over to change her, and then grabbed the resident's vaginal area through the brief. Resident 1 told CNA B not to touch her, and then CNA B left the room laughing. The Administrator stated he believed Resident 1, as she was honest and did not confabulate stories. During the same interview, the Administrator stated he had started his investigation of the incident and interviewed CNA B regarding the incident. He stated CNA B changed her statement regarding the incident, several times. The Administrator suspended CNA B, and when his investigation was completed, he terminated CNA B from her employment. During an observation and concurrent interview on 7/12/21 at 1:45 pm, Resident 1 was alert and oriented, well spoken, and became visibly upset and crying when talking about the incident. Resident 1 stated, on the night of the incident, she was not sleeping well. Resident 1 stated she was awake when CNA B entered her room for rounds check. Resident 1 further stated CNA B behaved as if she was high on drugs or alcohol, and, "She was really out there." Resident 1 stated CNA B was laughing as if she was mocking the resident and used rough language and handling while changing the Resident 1's brief. Resident 1 stated CNA B was saying weird things like, "What language do you speak?" Resident 1 stated she had only been in the facility for one month, so she had never received care from CNA B prior to this incident. During an interview with CNA A on 7/15/21 at 2:30 pm, she reiterated the same information she had given the Administrator regarding the incident. She also stated that the night of the incident, when she was signing off her shift, she saw CNA B. CNA B gruffly said she was in a bad mood. CNA A stated she did not pursue any further conversation about CNA B's state of mind at that time. CNA A stated she had only worked at the facility for a few months and did not know CNA B other than to see her at the facility. Record Review of CNA B's statement, written on 4/27/21, indicated she went to Resident 1's room to answer a call light at 11:35 pm on 4/26/21, and Resident 1 was harsh with her and seemed like she was mad. It further indicated CNA B went to get a brief for Resident 1, and Resident 1 was asking her what language she spoke. The statement further indicated, while changing the brief, she could not finish, and left the brief unhooked because Resident 1 told her not to touch her anymore. Record Review on 7/12/21, of CNA B's personnel file, revealed she had worked at the facility since 2018. She received a Corrective Action Verbal Notice on 8/24/18, for telling a resident she was not going to get her pain medicine when the resident had requested CNA B to ask the nurse for her med. On 1/10/19, she received another Corrective Action Written Notice and a Performance Improvement Plan for unprofessional and disrespectful communication with residents, as well as not accepting and taking directive from supervisory/management, lack of teamwork, and speaking in a threatening manner. On 2/15/19, she again received a Corrective Action for breaking a rule by working off the clock. Document Review on 7/12/21, of the facility's Abuse Prohibition and Prevention Policy and Procedure, dated 3/2018, indicated that each resident has the right to be free from abandonment, mental/emotional, isolation, involuntary seclusion, verbal, physical, financial, sexual, neglect, and misappropriation of property. Therefore, the facility failed to protect Resident 1 from abuse, when CNA B grabbed her vaginal area, forcefully, through her brief. This failure caused Resident 1 to cry and experience sadness when she felt physically and emotionally violated. The above violation has a direct or immediate relationship to the health, safety, or security of Resident 1.