Other·January 12, 2021

F600 ?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 physical abuse when Unlicensed Staff C grabbed both of Resident 1's forearms and forcibly walked her backwards, and pushed Resident 1 into a chair. This failure caused Resident 1 to experience anger, sadness, and fear. This failure also had the potential to negatively impact Resident 1's emotional health and dignity. On 4/23/20, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an allegation of physical abuse (employee to resident). A review of Resident 1's medical record document titled "DETAILED SUMMARY," not dated, indicated she was admitted on 2/27/19, with diagnoses that included "Dementia (A general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with Behavior Disturbance (Behavioral disturbances in dementia are often described as 'agitation' including verbal and physical aggression, wandering, and hoarding. These symptoms create patient and caregiver distress.)," and "Shared Psychotic Disorder (Presence of hallucination or delusions)." During an interview with Assistant Director A and Charge Nurse F, on 4/23/20 at 8:45 a.m., Assistant Director A stated she was informed by Administrator B, on 4/22/20, at 3:45p.m., that Resident 1 might have been the victim of physical abuse by Unlicensed Staff C. Assistant Director A stated Administrator B told her that Staff E reported Resident 1 attempted to slap Unlicensed Staff C, who then grabbed both of Resident 1's forearms and forcibly walked her backwards, and pushed Resident 1 into a chair. Assistant Director A stated Administrator B observed Staff E was very upset that someone would treat Resident 1 in that manner. During the same interview on 4/23/20 at 8:45 a.m., Assistant Director A stated Administrator B asked her to investigate and identify the Unlicensed Staff who was involved. She stated she immediately went to Nursing Station Four to speak with Charge Nurse F about the incident. Charge Nurse F stated that Unlicensed Staff D reported to her that while she and Unlicensed Staff C were trying to direct Resident 1 to take her daily shower, Resident 1 became resistant and shouted to both of the unlicensed staff that she did not want to take a shower and to leave her alone. Charge Nurse F stated Unlicensed Staff D observed Resident 1 become very agitated and came towards Unlicensed Staff C, and that was when Unlicensed Staff C forcibly grab Resident 1's wrists and forced her to sit down in a chair. Charge Nurse F stated Unlicensed Staff D was very distressed, crying and stated she felt Unlicensed Staff C's actions were inappropriate. During an interview on 4/23/20 at 9 a.m., Supervisor G stated on 4/22/20 at around 3:45 p.m., she was doing nursing rounds in nursing station four, at change of shift, and observed Resident 1's face was extremely red, she was verbally angry saying loudly, "don't touch me, don't touch me, get me out of here." Supervisor G stated that Resident 1 was usually very easy to redirect and stated she had never seen Resident 1 that angry before. Supervisor G stated she observed Unlicensed Staff D behind Resident 1. She stated Unlicensed Staff D looked distressed with a worried expression on her face. She stated Unlicensed Staff D started crying and described how Unlicensed Staff C grabbed Resident 1's arms and forcibly sat her down. She stated it made her feel very uncomfortable, and stated it just was not right to treat Resident 1 that way. During the same interview on 4/23/20 at 9 a.m., Supervisor G stated she confirmed the identity of Unlicensed Staff C with Staff E, and immediately communicated to Unlicensed Staff C she was being placed on Administrative Leave pending an abuse investigation. Supervisor G stated that Unlicensed Staff C stated she knew it was about how she treated Resident 1, and left the facility. Assistant Director A stated Unlicensed Staff C had been terminated after the investigation. During an interview with Manager H, on 4/23/20 at 11:42 a.m., she stated Staff E had come to her office on 4/22/20, at 4 p.m. to report a possible witnessed abuse incident around 3:37 p.m. on 4/22/20. She stated Staff E reported she was emptying the trash in [room number] in Nursing Station Four, when she witnessed Resident 1 yelling and very angry, saying "I will kill you, I will kill you," to Unlicensed Staff C. She stated Staff E told her she observed Unlicensed Staff C pushing Resident 1 with both hands, forcing Resident 1 to walk backwards and then pushing her down into a chair and then Unlicensed Staff C immediately left the area. During an interview with Staff E, on 4/23/20, at 11:37 a.m., she stated she observed Unlicensed Staff C grab both of Resident 1's arms and push her backwards for 10-12 feet in the Nursing Station Four hallway, and then forced Resident 1 to sit in a chair. She stated Resident 1 was screaming and yelling very loudly and Resident 1 looked very scared. She stated Unlicensed Staff C did not treat Resident 1 respectfully and was very rough with her. Staff E stated the treatment of Resident 1 was very bad. During an interview and record review, with Director J on 4/23/20 at 12:15 p.m., she stated every new employee had a job description that included information about patient rights, abuse and abuse reporting. She stated new employee orientation included at least a 4-hour training that included the mandated Department of Justice Video titled "Your Legal Duty," about the types of abuse and how to report abuse. She stated new employee orientation included information about a patient?s right to refuse and options available to staff like trying to get patients to shower at a different time, alert another team member or distraction. If a patient refuses to shower and staff cannot get them to shower, they should document the patient refusal and contact the family. A review of Unlicensed Staff C employee file indicated completion of new employee Abuse Training on 2/4/20. During an interview with Director of Staff Development (DSD) I, on 4/23/20, at 12:35 p.m., she stated she provided education about Abuse Prevention during new employee orientation and annual education for staff. She stated during the education, each employee was taught about the different types of abuse, including physical abuse. She stated the difference between guiding a Resident with cognitive impairment and physical abuse was how the resident perceives the interaction. DSD I stated a resident with dementia communicated distress by being agitated, looking distressed or crying out. If the resident does not want to do something, you cannot force them. She stated the facility provided education to employees on how to provide resistant dementia residents with a distraction, try with different staff, options to guide patients to do something they are resistant to do. She stated employees should never try to force a resident to do something they do not want to do. A review of a record titled "Interdisciplinary Notes," dated 4/22/20, at 4:51 p.m. for Resident 1, indicated "This writer observed Res [Resident] to be in emotional distress @ 1540 [3:40 p.m.] and displaying emotions of anger and sadness r/t [related to] event on 4/22/20. Res was noted to be more anxious/distraut and trying to walk away from this writer when speaking. Once Res was able to calm down after a few minutes, she started repeating statements of "help, get me out of here." A review of facility policy and procedure (P&P), titled "Abuse Investigation and Reporting," revised 7/2017, indicated, "If the investigation reveals that the allegations(s) of abuse are founded, the employee(s) will be terminated." A review of document titled "Your Legal Duty ...Reporting Elder and Dependent Adult Abuse," dated 2016, indicated "Welfare and Institutions Code Section 15610.63. "Physical abuse" means any of the following: ... Use of a physical or chemical restraint or psychotropic medication [medication is used to treat mental illnesses] under any of the following conditions: ...For punishment. ...For any purpose not authorized by the physician and surgeon. ...Examples of Physical Abuse: ...A resident refuses to get out of bed when encouraged ... The nurse then forcefully pulls the resident from a reclining to an upright position in his bed, pushes him out of his room, as the resident screams and cries to be left alone." The facility failed to protect one resident (Resident 1) from physical abuse when Unlicensed Staff C grabbed both of Resident 1's forearms and forcibly walked her backwards, and pushed Resident 1 into a chair. This failure caused Resident 1 to experience anger, sadness, and fear. This failure also had the potential to negatively impact Resident 1's emotional health and dignity. The above violation has caused or is likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the resident.