Other·July 15, 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 ensure one of two sampled residents (Resident 1) was free from abuse when Resident 1's left ankle was found to be tied to the bed frame. This failure had the potential to negatively impact the resident's well-being and put the resident at risk for further harm. Findings: Review of the facility's P&P titled Abuse Prevention Program revised August 2021 showed the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. As part of the resident abuse prevention, the administration will protect our residents from abuse by anyone including, but not necessarily limited to, facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Medical record review for Resident 1 was initiated on 4/27/22. Resident 1 was admitted to the facility on 12/15/21. Review of the facility's Final Investigative Summary Report (undated) showed CNA 1 reported to the charge nurse (LVN 2) that Resident 1's left ankle was tied to the bed frame using a bed sheet. The document showed the facility substantiated the allegation of abuse. Review of Resident 1's MDS dated 3/23/22, showed Resident 1 was severely cognitively impaired and required assistance from facility staff for his ADL care. On 4/27/22 at 1254 hours, a telephone interview was conducted with CNA 1. CNA 1 stated he worked on 4/25/22, and was assigned to care for Resident 1. CNA 1 stated Resident 1 was forgetful and had a behavior of climbing out of the bed. CNA 1 stated Resident 1 would drop his legs off the bed. CNA 1 stated on 4/25/22, he was assigned to Resident 1 for the 0700 to 1530 hours shift and another CNA took over Resident 1's care for the 1500-2300 hours shift. CNA 1 stated around 1610 hours, he was walking past Resident 1's room and noticed from the hallway Resident 1's left ankle was tied to the bedframe. CNA 1 stated he immediately informed LVN 1 and they both went to Resident 1's room. CNA 1 stated he heard LVN 1 reported to the DON that Resident 1's left ankle was tied to the bed frame. On 4/27/22 at 1204 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 1 was not fully alert and oriented. LVN 2 stated CNA 1 informed her that Resident 1's left ankle was tied up and needed her to see Resident 1. LVN 2stated she observed Resident 1 was observed with his left ankle tied with a folded bedsheet to the bedframe. LVN 2 stated she attempted to untie the resident's left ankle but needed the assistance of CNA 1 because the knot was difficult to remove. LVN 2 stated she found no visible injuries on Resident 1. LVN 2 stated she immediately reported the incident to the DON. On 4/27/22 at 1346 hours, an interview was conducted with the DON. The DON stated he was made aware of the incident and acknowledged the above findings. This violation had a direct or immediate relationship to the health, safety, or security of residents.