Other·November 10, 2021

§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 2) was free from abuse. * Certified Nursing Assistant (CNA) 5 pushed Resident 2 onto the floor and dragged him by the arm down the hallway to his room. This failure had the potential to cause serious injuries and/or psychosocial harm to the resident. Findings: Review of the facility's policy and procedure (P&P) titled Abuse Prevention Program revised December 2016 showed each resident has the right to be free from abuse. Review of the facility's P&P titled Pro-ACT (Professional Assault Crisis Training and Response) showed all employees shall utilize their Pro-ACT Training and learned approaches to respond to resident behaviors. Responses to specific types of behaviors include but are not limited to the following. For non-threatening behaviors: walk away if safe, offer alternatives, listen, attempt to re-direct, be calm and lower voice. For aggressive or threatening behaviors: set limits and offer alternatives, use communication and alternatives to de-escalate, attempt to distract or redirect, talk and listen, attempt de-escalation techniques, consult with other team members for assistance. Review of the facility's P&P titled Seclusion and Restraints revised 7/26/18, showed in the event of perceived imminent violence - staff will notify available team members and follow Pro-Act procedures in attempt to de-escalate the resident. During the intervention, staff members will use team control position to manage individuals who become dangerous to themselves or others. Staff members who are holding the individual should: face the same direction as the acting out person while adjusting as necessary to maintain close body contact with the individual or may restrain resident against a wall or lower resident prone to the floor. Review of the SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) dated 8/17/21, showed the facility reported an allegation of physical abuse on Resident 2. The report showed CNA 5 pushed Resident 2 during the behavioral crisis intervention at the TRC unit of the facility. Medical record review for Resident 2 was initiated on 8/26/21. Resident 2 was admitted to the facility on 2/4/21. Review of Resident 2's Minimum Data Set (a standardized assessment) dated 5/20/21, showed Resident 2 was cognitively intact and independent on walking and activities of daily living (ADL) care. On 8/26/21 at 1100 hours, an interview and concurrent medical record review was conducted with the Program Director. Review of the facility's abuse investigation showed the alleged abuse occurred on 8/16/21 at 2345 hours. The Program Director stated the abuse investigation showed Resident 2 had exhibited behaviors of agitation and noncompliance to the staff's requests at the time of the alleged abuse. Resident 2 had received several medications for behavior management and was unsteady walking and appeared drowsy. The facility staff requested Resident 2 to lay down on the bed in his room for his safety. However, Resident 2 continued to refuse to go to his room. The investigation showed on 8/17/21 at approximately 2345 hours, six staff members were reportedly walking beside and behind Resident 2 and attempted to walk with the resident back to his room. CNA 3 reported while walking Resident 2 towards his room, she witnessed CNA 5 pushing Resident 2 three times from behind and Resident 2 fell on the floor. CNA 5 then dragged Resident 2 by the arm down the hallway to his room. The Program Director stated the incident occurred on 8/16/21 at approximately 2345 hours; however, the incident was not reported to the Director of Nursing (DON) until 8/17/21 at approximately 0730 hours, almost seven hours after the incident had occurred. On 8/26/21 at 1100 hours, an interview and concurrent abuse investigation review was conducted with the Program Director. Review of the abuse investigation report showed the Program Director began the investigation after being notified at approximately 1000 hours. The investigation report showed the Program Director interviewed Resident 2, CNAs 1, 2, 3, 4, Licensed Vocational Nurse (LVN) 1, and the alleged perpetrator, CNA 5. On 8/17/21, Resident 2 told the Program Director in the initial interview that he had no recollection of what occurred the previous night; however, on 8/17/21, in the afternoon, he reported to the Social Worker that he was pushed down by CNA 5. The Program Director stated CNA 5 denied he pushed Resident 2 down to the ground and dragged him to his room by his arm. CNA 5 told the Program Director that he placed his hands on Resident 2 because he was staggering, and the resident fell down on his own. CNA 5 also stated he grabbed the arm of Resident 2 to help him stand up and Resident 2 stood up and went to his room. Review of the Skilled Note dated 8/15/21 at 2037 hours, showed Resident 2 was being monitored for 24 hours for increased agitation and aggression. The documentation showed no episode of agitation and aggression was observed and Resident 2 was visible on the unit socializing with selected peers. Review of the Psychiatrist Progress Note dated 8/16/21 at 1254 hours, showed Resident 2 had been observed to be irritable, refused his morning medications, claimed he was too sleepy, easily angered, and was not willing to discuss the plan for how he would provide his own care. The documentation showed Resident 2 complained of inability to fall asleep until 0300 hours. A new order for Seroquel (antipsychotic medication) was added for the resident. Review of the Progress Notes showed the nursing entries dated 8/16/21 at 2227, 2245, and 2327 hours, showing Resident 2 was given the PRN (as needed) medication three times for increased agitation, anxiety, aggression, and odd behaviors. Resident 2 was also provided with encouragement to relax in bed and use his coping skills as a way for the medication to help him to calm down and sleep. Further review of the medical record failed to show any documentation of the alleged abuse incident that had occurred on 8/16/21 at 2345 hours. There was no documented evidence a physical examination was conducted immediately after the incident. Review of the facility's staffing schedule dated August 2021 showed CNAs 1, 2, 3, 4, and 5 were working on the TRC unit of the facility on 8/16/21, during the 1600 to 0030 hours shift. On 8/26/21 at 1648 hours, an interview was conducted with CNA 2. CNA 2 verified she was working at the facility on the evening shift from 1600 to 0030 hours on 8/16/21. CNA 2 was asked to describe the events which took place surrounding Resident 2 on 8/16/21. CNA 2 stated at approximately 2230 to 2300 hours, Resident 2 went into the rooms of other residents, laid down on the floor; and when LVN 1 talked to him, the resident did not want to get up and go back to his own room. CNA 2 stated CNA 5 was also asking Resident 2 to go back to his room. CNA 2 stated there were six staff members present to walk Resident 2 back to his room, LVN 1 was the team leader. Resident 2 was waving his arms and saying he did not want to go back to his room. CNA 2 stated CNA 5 then put his hands on Resident 2's shoulders and quickly pushed him from behind, Resident 2 was unsteady and fell down. Resident 2 was on the floor and CNA 5 grabbed him with both arms and pulled him about six feet down the hallway to his bedroom. CNA 2 stated Resident 2 was fighting not to go back to his room. CNA 2 stated the way CNA 5 responded was not how they were trained using the Pro-ACT techniques. CNA 2 stated in the Pro-ACT training classes, they were taught to work as a team for the safety of the residents and to not do anything that would hurt the residents. According to CNA 2, in this situation the team should have stood to the side of the resident and waited for LVN 1, the team leader, to give them instructions. CNA 2 stated she did not report the incident to anyone and thought LVN 1 was going to report it to Licensed Psychiatric Technician (LPT) 2, the Charge Nurse for the shift. CNA 2 stated the abuse should immediately be reported to the Supervisor and verified she did not ensure the suspected abuse she witnessed was reported immediately to the Charge Nurse. On 8/26/21 at 1721 hours, an interview was conducted with CNA 1. CNA 1 stated he worked at the facility in the evening shift on 8/16/21, and witnessed the incident that occurred with Resident 2. CNA 1 stated there were six staff members present with Resident 2 at the time of the incident. CNA 1 stated Resident 2 was having a hard day and repeatedly came to the nurse's station. CNA 5 was attempting to stop Resident 2 from coming to the nurse's station. CNA 1 stated CNA 5 put up his hands and Resident 2 was swiping at his hands as the staff were trying to talk to Resident 2. CNA 1 stated he observed Resident 2 on the floor near the drinking fountain; however, did not observe how he fell. CNA 1 stated he observed CNA 5 grabbing Resident 2 by both arms and pulled him down the hallway to his room. CNA 1 stated he was speechless at what he had observed. CNA 1 stated Resident 2 was not hurting anyone and according to his training, he would have left him alone when he was lying on the ground. When CNA 1 was asked who he reported the incident to, he stated he was not sure what he observed was an abuse and did not tell anyone about the incident that he had witnessed. CNA 1 stated LVN 1 debriefed the team after the incident and told CNA 5 she did not like what he had done to Resident 2. CNA 1 stated he thought LVN 1 was going to report the incident. CNA 1 stated the abuse training was completed frequently at the facility and stated all suspected abuse should be reported immediately to the Administrator. CNA 1 verified he did not ensure the Charge Nurse and Administrator were notified of CNA 5 pulling Resident 2 down the hallway by his arms. On 9/22/21 at 1100 hours, a telephone interview was conducted with CNA 4. CNA 4 stated he was working at the facility on 8/16/21, and was a team member during the behavioral intervention with Resident 2. CNA 4 stated Resident 2 received the PRN medication at approximately 2230 hours, for escalation of behaviors. CNA 4 observed Resident 2 was sleepy and unsteady when walking. CNA 4 observed CNA 5 asking Resident 2 to go back to his room. Resident 2 refused and CNA 4 observed CNA 5 pushing Resident 2 three times from behind, but not too hard. CNA 4 stated Resident 2 fell to the ground near the water fountain. CNA 4 stated Resident 2 sat up and CNA 5 asked him again to go to his room. Resident 2 laid back down on the ground. CNA 4 stated Resident 2 did not appear injured. CNA 4 stated he observed CNA 5 quickly grabbing the right arm of Resident 2 and dragging him more than 10 feet down the hallway to the resident's room. CNA 4 stated CNA 5 was very strong and seemed mad. CNA 4 stated he asked CNA 5 to stop dragging Resident 2 down the hallway, but CNA 5 did not stop and continued to drag Resident 2 down the hallway. CNA 4 stated LVN 1 observed the incident and he heard LVN 1 telling CNA 5 that he had a problem. CNA 4 stated the abuse training was completed regularly at the facility and the behavior management training taught the staff to work as a team, call for help, and not try to handle a situation alone. CNA 4 stated the Abuse Coordinator was the Administrator. When asked if he reported the incident to the Charge Nurse or the Administrator, CNA 4 stated he did not report what he had witnessed to anyone and thought LVN 1 had reported it to the Charge Nurse, LPT 2. On 9/21/21 at 1555 hours, a telephone interview was conducted with LVN 1. LVN 1 recalled she gave Resident 2 the PRN medication for increased agitation and anxiety on the evening shift but could not recall the date. LVN 2 stated she had not witnessed any incidents of abuse to Resident 2 and could not recall an incident where she was the Team Leader. LVN 1 stated if a resident was mistreated, she would separate the resident and the staff member and immediately report the incident to the Charge Nurse. On 8/26/21 at 1200 hours, a follow-up interview was conducted with the Program Director. The Program Director verified the facility's P&P was not followed during the behavior intervention with Resident 2. The Program Director stated pushing and dragging a resident by the arm was not part of the facility's behavior management training and considered as an abuse. The Program Director stated when a resident was acting out and lying on the floor not harming himself or anyone else, the appropriate response would be to allow him to lay there. The Program Director stated the abuse was not tolerated at the facility and should have been reported immediately to the Charge Nurse and Administrator. Review of a letter sent to California Department of Public Health Licensing and Certification Program from the Program Director on 8/20/21, showed the allegation of abuse was substantiated. CNA 5's employment at the facility was terminated on 8/17/21. This violation, jointly, separately, or in any combination had a direct or immediate relationship to the health, safety or security of patients or residents.