Other·April 20, 2021

F607, §483.12(b)(1)-(3) DEVELOP/IMPLEMENT ABUSE/NEGLECT POLICIES §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, On 3/24/21 at 1:30 p.m., an unannounced visit was conducted at the facility to investigate a facility reported incident, Quality of Care/Treatment, Resident Safety regarding the facility's failure to ensure a resident (Resident 1) was free from physical and mental abuse, and failed to ensure a staff (certified nursing assistant B, CNA B) who was a witness had immediately reported the incident for one of two sampled residents when: 1. Nurse Assistant A (NA A) pinned down Resident 1; and when 2. CNA B did not immediately report the incident to the charge nurse upon witnessing it. This failure resulted in emotional distress to the resident and the failure of late reporting delayed action to protect Resident 1 and other residents from the potential of further abuse. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 1/6/21, indicated the resident did not have any problems with memory and with daily decision skills. During an interview on 3/4/21 at 2:15 p.m., Resident 1 stated, "Yesterday evening [NA A] kicked my door and the door swung open. I said to her you need to get out of here. [NA A] then grabbed my wrists and pinned me down. When I said you need to let me go, [NA A] responded, 'If I don't, what are you going to do?'" Resident 1 stated, "The incident scared the hell out of me." Review of Resident 2's MDS, dated 12/24/2020, indicated the resident had mild impairment with memory and daily decision-making skills. During an interview on 3/4/21 at 2:08 p.m., Resident 2 stated she witnessed the following, "Yesterday evening, [NA A] kicked the door open, making a booming sound, which startled [Resident 1]. [NA A] entered the room and hugged me. [Resident 1] said what are you doing? [NA A] pinned [Resident 1]'s arms down. When [Resident 1] said get your hands off of me, [NA A] said, 'What are you going do, beat me up?' [CNA B], who saw the incident, 'freaked out' and went out of the room to get help. [Resident 1] cried." Resident 2 stated she knew NA A for a while and NA A's behaviors were loud, rude and acting out. During an interview on 3/4/21 at 3:10 p.m., charge nurse C (CN C) stated yesterday, when passing medications around 8:15 to 8:30 p.m., Resident 1 informed her about being abused by NA A. CN C stated Resident 1 was crying and had a terrified look on her face. CN C stated Resident 1 told her she had not been pinned down like that since she was a child. CN C stated she felt terrible and she called CNA B to ask what happened. During an interview on 3/4/21 at 3:25 p.m., CNA B stated she witnessed the incident. CNA B stated, "Yesterday, around 7:30 to 7:40 p.m., [NA A] was in the hallway, had her back against [Resident 1]'s door with hands raised near the head level and she was repeatedly knocking the door with her foot and hands. She asked [NA A] to stop. [NA A] entered the room, hugged [Resident 2] and approached [Resident 1]. [Resident 1] said, 'Don't do that,' referring to the door knocking. [NA A] held down [Resident 2]'s shoulders with both of her hands and asked [Resident 1], 'What are you going to do about it?' I told [NA A] to stop and [NA A] left the room. [Resident 1] said, 'Do not let [NA A] back in my room.'" CNA B stated she did not immediately report the incident because CN C was on dinner break and that she also went on break. Later that evening CN C called and asked her what happened. Review of Resident 1's Health Status Note, dated 3/3/21 at 11:31 p.m., indicated Resident 1 reported NA A kicked her door, pinned her right and left wrists down and stated to her, "What are you going to do about it?" The same entry indicated Resident 1 did not want NA A in her room again. During an interview on 3/4/21 at 1:30 p.m., the administrator stated the incident likely happened because both Resident 1 and CNA B said the same things regarding NA A pinning down Resident 1. She stated CN C informed her yesterday evening and she suspended NA A. During a follow-up interview on 3/4/21 at 5 p.m., the administrator stated staff should have reported the incident right away before going on a break. Review of the facility's "ABUSE PROHIBITION AND PREVENTION POLICY AND PROCEDURE," dated 03/2018, indicated this facility prohibits and prevents abuse. Under the Reporting/Response section, it indicated all mandated reporters were to report reasonable suspicion of a crime against a resident. The policy did not indicate the timeframe for reporting. Under the Protection section, it indicated if the suspected perpetrator was an employee to remove employee immediately from the care or vicinity of residents. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.