Other·October 3, 2022

Health & Safety Code 1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours. A failure to comply with the requirements of this section shall be a class "B" violation. Based on interview and record review, the facility failed to report alleged abuse and neglect to the Department within 24 hours for eight (Resident 1, Resident 2, Resident 4, Resident 5, and Resident 6, Resident 7, Resident 8, Resident 10) of 15 sampled residents. This failure resulted in alleged abuse to continue with no facility intervention and with the Department being unaware of alleged abuse. Findings: On 1/6/22, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an allegation of abuse/neglect. Resident 1 was a 73-year-old male who was admitted to the facility on 6/2/21 and had a history of Chronic Obstructive Pulmonary Disease (a disease of the lungs), urinary infections, and major depressive disorder (persistent feelings of sadness). Resident 2 was a 68-year-old male who was admitted to the facility on 5/26/21 and had a history of major depressive disorder, pneumonia, and type 2 Diabetes Mellitus (Diabetes - a condition that effects the blood sugar). Resident 4 was a 63-year-old female who was admitted on 7/1/21 and had a history of severe intellectual disability (disability of thought processes and mental capability, arthritis, and insomnia (trouble sleeping). Resident 5 was a 79-year-old female who was admitted on 6/2/21 and had a history of anxiety, major depressive disorder, facial weakness, and chronic obstructive pulmonary disease. Resident 6 was a 60-year-old male who was admitted on 6/13/21 and had a history of quadriplegia (unable to move body from the neck down), major depressive disorder, urinary tract infections, and chronic pain. Resident 7 was a 56-year-old female who was admitted on 7/1/21 and had a history of dependence on wheelchair, major depressive disorder, and dysphagia (trouble swallowing). Resident 8 was a 62-year-old male who was admitted on 6/4/21 and had a history of hemiplegia/hemiparesis (brain injury that results in lack of control for one side of the body), and dysphagia. Resident 10 was an 86-year-old female who was admitted on 6/4/21 and had a history of hemiplegia/hemiparesis, Alzheimer's disease, and repeated falls. During a review of the facility record (FR), dated 12/24/21, the FR indicated, "On December 19, 2021 at approximately [7:30 PM], I [Director of Nursing - DON] was performing a yearly evaluation with one of my [night shift] nurses. During the process of this evaluation, [Licensed Vocational Nurse - LVN 1] had stated 'there was a problem with [CNAs 1] leaving her residents in bed soaked with urine'. [sic] I [DON] asked her to write me a report on the incidence. . . December 20, 2021 - When I [DON] came to work, I read the report in which [LVN 1] wrote. It stated 'During night shift on 12/19/2021, it was brought to my attention that [Resident 8], bedding was soaked through the linens. This complaint has come from CNAs on my shift at different times over the last few weeks. The same CNA [CNA 1] has been the one they followed'. [sic]. . .One of the CNAs that works [LVN 1's] shift is [CNA 2]. I called [CNA 2], and asked her if she knew of any issues happening with day shift CNAs daily care. She verbally gave me a report on the phone regarding [CNA 1] care especially with [Resident 8]. After the conversation, I then asked her to write up a statement. . .I [DON] then assessed ALL residents for rashes, redness or any other skin issues who were incontinent of bowel and bladder. . . I [DON] found six total in which I immediately placed on a [every] 2 hour check and change related to mild redness. . . [Resident 1]. . .Redness noted placed on [every] 2 hours checks and changes. . .[Resident 2]. . .Redness and excoriation [wearing off of skin] of scrotum area. . ." During an interview on 1/6/22, at 10:15 AM, with DON, DON stated, she first became aware of CNAs 1's abuse and neglect of residents on 12/19/21. DON stated despite being informed on 12/19/21, her investigation uncovered abuse and neglect by CNA 1 had been going on for weeks and that staff were aware. Although the DON was not informed. During an interview on 1/6/22, at 10:40 AM, with LVN 1, LVN 1 stated, she noticed issues with CNAs 1 neglecting her residents a few weeks prior to 12/19/21, around the end of November or beginning of December 2021. LVN 1 stated she noticed other CNA's complaining that CNA 1's assigned residents would be soaked and wet with urine. LVN 1 stated the incidents were occurring more often and increasing in frequency until reported on 12/19/21. LVN 1 stated some residents under CNA 1's care would have soaked briefs through the linens and through their mattress. LVN 1 stated, "For weeks I would have CNA's state she's [CNA 1] was the worst CNA to follow." LVN 1 stated, "I should have reported it to [DON] because it was neglect on [CNA 1's] part for not taking care of residents properly." During a follow up interview on 6/16/22, at 2:36 PM, with LVN 1, LVN 1 stated, she was getting verbal reports from CNA 2 and CNA 3 that CNA 1 was the worst staff member to take over care of residents. CNA 2 and CNA 3 would report many job duties were not getting done by CNA 1. These job duties included stocking of resident rooms, removing of old resident meal trays, basic care needs (answering call lights, ensuring fluids are within reach, incontinent care) for residents, throwing out resident trash and changing residents when soiled. LVN 1 stated she followed up on CNA 2 and CNA 3's complaints and noted: Resident 8 soaked through his briefs, bed pads, bedding, and mattress; Resident 1 soaked with urine; Resident 5 soaked with urine through her brief and bedding; Resident 2 soaked with urine through his briefs, bed pads, and bedding. LVN 1 stated CNA 1 left the residents soaked in urine on several occasions but could not recall the exact dates. LVN 1 stated these issues became more prominent starting in November of 2021. LVN stated the issues came to the point of being resident neglect around a week and a half prior to 12/19/21. LVN 1 stated it reached the level of neglect when CNA 1 continued to leave her residents unattended and soaked with urine continuously. LVN stated the skin irritation and redness were a direct cause from CNA 1's lack of provision of care. LVN 1 stated she should have reported the neglect but did not, "it was an error on my part." During an interview on 6/16/22, at 3:20 PM, with CNA 3, CNA 3 stated, she noticed CNA 1 neglecting residents at the beginning of December 2021. CNAs 3 stated on 12/19/21, she had taken over CNA 1's residents to begin her shift at 6:30 PM. CNA 3 stated she immediately noticed Resident 8 was soaked in urine from head to toe. CNA 3 stated she had to completely change Resident 8's bedding, provide a bed bath, wash his hair from urine, and clean up the room. CNA 3 stated Resident 8's skin was inflamed from sitting in the urine soaked bed. CNA 3 stated she had also noted on 12/19/21 that Resident 7's bathroom door was locked. CNA 3 stated CNA 1 reported she locked Resident 7's bathroom door because Resident 7 was trying to get up and use the restroom. CNA 3 stated as of 12/19/21 she considered lack of provision of care to residents by CNA 1 had reached the level of neglect but did not immediately report it as abuse. During a review of CNA 2's written statement (WS), dated 12/21/21, the WS indicated, "[CNA 1] didn't empty Foley [A bag that collects urine from a tube inserted directly into the resident bladder] for [Resident 6] a nor [sic] [Resident 8 or Resident 1] these [Foley] were full . . . [Resident 5] had to go to bathroom so bad she was crying . . . [Resident 4] was in the same boat as soon as I [CNA 2] walked in door at [6:10 PM] they [Resident 4, Resident 5] started hollering . . . [Resident 6] was soaking and had b/m [bowel movement - feces] every where [sic] what was so bad about situation is it wasn't the only time we have talked to her [CNA 1] . . . one morning she [CNA 1] came in didn't get report yet and went outside to smoke . . . she [CNA 1] told [Resident 8] that night would get his water for him he didn't have any . . . She [CNA 1] told [Resident 7] that they would have to wait until nightshift [sic] to go to restroom." During an interview on 7/18/22, at 10:40 AM, with CNA 2, CNA 2 stated, she would take over care for CNA 1's residents when her shift was over and also give report to CNA 1 when CNA 2's shift ended. CNA 2's shift was from 6:30 PM to 7 AM. CNA 2 stated when CNA 1 would clock in to begin her shift (about 6:30 AM) she would immediately take a 30 minute smoke break rather than begin working. CNA 2 stated she noted the following resident issues associated with CNA 1's lack of care starting in the late summer early fall of 2021: 1. Resident 10's brief was left with dry feces and/or she would have her brief soaked with urine all the way through the bedding. 2. Resident 7 had wet feces all the way up to her bra line, covering her head and back. Also noted her bathroom door was locked so she could not use the restroom. CNA 2 stated the condition Resident 7 was left in and the locking of her bathroom door was very worrisome. CNA 2 stated she noticed these issues starting in October of 2021 with Resident 7's lack of care. 3. Resident 8's Foley catheter bag was full. CNA 2 stated she also observed dry feces on Resident 8's brief. CNA 2 stated she placed a time and date on Resident 8's brief when she left him in CNA 1's care. When CNA 2 returned 12 hours later to take over CNA 1's care she noted his brief had dry feces and he still had the timed and dated brief she had placed on him earlier. CNA 2 stated she could not recall the exact date she placed the timed brief on Resident 8. 4. Resident 6 left with his Foley catheter bag full of urine from not being emptied throughout CNA 1's shift. 5. Resident 1 left with his Foley catheter bag full of urine from not being emptied throughout CNA 1's shift. 6. Resident 5 was observed trying to get to the restroom (cannot recall exact date). Resident 5 was very distressed. She was crying and couldn't talk or get any words out. She was soaking wet when CNA 2 found her. She is a resident if you take her to the restroom, she will use the toilet and not have incontinent episodes as much. CNA 2 stated these incidents with resident neglect by CNA 1 went on for about three to four months. CNA 2 stated she spoke with CNA 1 about the care issues, but CNA 1 would state she knew how to do her job. CNA 2 stated the neglect resulted in Resident 10 having severe redness to her buttocks and resulted in distress for Resident 5 because of the crying from being left wet with urine. CNA 2 stated she is a mandated reported and should have reported the neglect, but did not out of fear of retaliation from co-workers that worked with CNA 1. CNA 2 stated she would notice only CNA 1's residents that were not alert or able to verbalize issues were affected with neglect. CNA 2 stated, "When you walk in and see a resident [Resident 5] crying because she was not taken to the restroom it breaks your heart and makes you angry." During an interview on 1/6/22, at 10:57 AM, with LVN 2, LVN 2 stated, she would get reports from staff that when CNAs 1 would provide care to Resident 8, he would be found left "saturated" in urine by the oncoming shift. LVN 2 stated she would get these reports starting in early December. LVN 2 stated she did not report these incidents to leadership (DON). During a review of LVN 2's WS, dated 12/21/21, the WS indicated, "I [LVN 2] have received in report from night shift nurses that Night [sic] CNAs reported that residents are soaked with urine when following this employee [CNA 1]. She takes multiple breaks during the day and is hard to find at times during shift." During an interview on 7/9/22, at 10:05 AM, with LVN 2, LVN 2 stated, she worked with CNA 1 during her shift (7 AM to 7:30 PM) about twice a week. LVN 2 stated CNA 1 was hard to find, always outside on breaks, and would need to track her down to get her to change her assigned residents. LVN 2 stated staff on the shift would try to find CNA 1 because they would have to answer her resident call lights and the staff could not find CNA 1. LVN 2 stated she would get report from LVN 1 that CNA 1 would leave her residents saturated with urine. LVN 2 stated she recalled Resident 8 was left saturated. LVN stated she did not know other nursing staff had issues with CNA 1's care of her residents until CNA 1 was longer employed. LVN 2 stated it was different staff members that came forward and said CNA 1 was not caring for her residents. LVN 2 stated the CNA 1's lack of care provided to her residents became bigger than she was first aware of. LVN 2 stated around December 2021, it appeared CNA 1 was no longer caring for her residents and was more concerned with taking her breaks or smoking. LVN 2 stated in a 12-hour shift CAN 1 would take at a minimum, one break every hour. LVN 2 stated CNA 1's alert and verbal residents had no issues but toward the end of December 2021, CNA 1 was neglectful with her time management in regard to her nonverbal, bedbound residents. During a review of LVN 3's WS, dated 12/21/21, the "WS" indicated, "This e-mail is to inform you of multiple times when [Resident 8] was left entirely soaked completely through his brief, pad, and bed linens at change of shift. At one time residents brief was timed by [night shift] CNA at 4 am and upon returning to work that night [CNA 1 worked the day shift after] residents still had the same timed brief on. [Resident 10] also had the same experience with soaked brief, pad and bed linens. [Resident 7] had watery stool all the way up to her shoulders while sitting in her [wheelchair] for several hours. All of this is a result of the same CNA, [CNA 1]. Just to let you also know, [CNA 1] . . . come to work at 6:30 am only to sit around for at least 45 min [minutes] before even get started [sic]. I [LVN 3] usually go home around 7:15 to 7:30 [am] and they are either MIA [missing in action], smoking, in the bathroom or doing nothing." During an interview on 6/15/22, at 11:16 AM, with CNA 7, CNA 7 stated, she had worked with CNA 1. CNA 7 stated she would get complaints from residents regarding CNA 1's lack of care. CNA 7 stated Resident 1, Resident 10, Resident 5, and about three other residents (she could not recall) would complain CNA 1 was rough and inappropriate when providing care (no specifics details given). CNA 7 stated these complaints from the residents about CNA 1 would occur sporadically throughout the time CNA 1 worked at the facility. CNA 7 stated she could not recall exact dates. CNA 7 stated she did not report these allegations. CNA 7 stated what the residents told her should have been reported as allegations of abuse. CNA 7 stated the resident complaints were only about CNA 1 and no other staff member. During an interview on 6/15/22, at 1:28 PM, with Infection Preventionist (IP), IP stated, she would get reports from CNA that total bed changes for residents saturated with urine would have to be done after taking over CNA 1's assigned incontinent residents. IP stated she recalled CNA 2 and CNA 3 mentioning this but could not recall who were the other CNA that complained about CNA 1. IP stated she encouraged the CNA to report these issues to the DON. IP stated she remembered CNA 2 placing a date and time on a resident in November and/or December of 2021 to show that CNA 1 was not changing her residents during the whole 12 hour shift. IP stated CNA 1 would take a lot of breaks and go smoke a lot throughout her shift. During a review of the Department's reported allegations, there was no evidence the alleged incidents of abuse and neglect for Resident 1, Resident 2, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, and Resident 10, were reported to the Department timely. During a review of the facility's policy and procedure (P&P) titled, "ABUSE PREVENTION PROGRAM" dated