Other·February 11, 2022

42 CFR §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 following reflects the findings of the California Department of Public Health during the investigation of a Facility Reported Incident #752054. On 9/10/21, an unannounced visit was conducted at the facility to investigate the facility reported incident regarding resident abuse. Resident 1 is an 82-year-old male who was admitted to the facility on 6/28/2021and has a diagnoses of Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and anxiety disorder, unspecified (mental health disorder characterized by feelings of worry, anxiety, or fear). Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from abuse when Certified Nursing Assistant (CNA) 1 was allowed to continue to care for Resident 1. This failure resulted in Resident 1 sustaining skin bruising (discoloration) to hands, wrists, and abrasions (injury to the skin caused by force) to the left forearm and right shoulder which caused Resident 1 pain and emotional distress. During a review of Resident 1's "Progress Notes," dated 9/8/21, at 10 PM, the Progress Notes indicated, "At this time resident sitting at nursing station in geri chair [reclining chair on wheels]. Resident is sitting with legs hanging over the side of geri chair. When CN [charge nurse-Licensed Vocational Nurse (LVN) 1] attempted to reposition resident into geri chair correctly resident is noted with black/purplish discoloration to bilateral hands and wrists. . .Resident is grimacing (sign of discomfort) when left wrist is moved up and down." During a review of "Report of Suspected Dependent Adult/Elder Abuse" (SOC 341), dated 9/8/21, the SOC 341 indicated, "Resident [1] was up in a geri chair 1:1 (1 staff to 1 resident) with a CNA [1] in the staff break room near the nurses station. LVN [1] witnessed CNA [1] lift resident's legs up causing him to fall back in the geri chair as he was trying to stand. The nurse overheard CNA [1] say, "Im (sic) done watching you" then walked away and went to sit in the staff break room. LVN [1] abserved [sic] new brusing [sic] to right and left hand/wrists and noted what appears to be brusing [sic] from fingers on the right hand. . .Reported types of abuse. . .Physical. . ." During a review of the facility's "Investigation Report," dated 9/9/21, the Investigative Report indicated, "Upon further investigation, footage of surveillance camera revealed [CNA 1] sitting in the staff break room on the night of 9/8/21 with [Resident 1]. Resident [1] was sitting in a geri chair and made two attempts to rise from the chair. Resident [1] struck [CNA 1], [CNA 1] then stood up and appeared to strike resident in the upper body. [CNA 1] then walked out of the break room, then returned seconds later and pushed resident out into the hallway, in front of the nurse's station. [CNA 1] then returned to the break room and sat there until she left the building." During a review of Resident 1's "Brief Interview for Mental Status" (BIMS-screening tool used to assist with identifying a resident's current cognition, a score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 0-7 indicates severe cognitive impairment), dated 7/5/21, the BIMS indicated, Resident 1's BIMS score was 6. During an interview on 9/10/21, at 9 AM, with Director of Nursing (DON), DON stated, on 9/8/21, during the night staff telephoned her stating they suspected staff of abusing Resident 1. DON stated, LVN 1 reported she was sitting at the nurse's station when CNA 1 came out of the staff break room with Resident 1 in his geri chair. DON stated, LVN 1 reported CNA 1 placed Resident 1 at the nurse's station and said I'm done watching you. DON stated, LVN 1 reported she attended Resident 1 when he attempted to get out of the geri chair and saw bruising on Resident 1's hands. Resident 1's assessment indicated black/purplish discoloration to both hands, left wrist and, an abrasion to the left wrist and right shoulder. During an interview on 9/10/21, at 9:28 AM, with DON, DON stated, when she arrived at the facility that night (9/8/21), she assessed Resident 1. DON stated, the bruising on Resident 1's hands showed an imprint of three fingers to the top of both hands. DON stated, during her interview with CNA 1, CNA 1 said Resident 1 had hit her, spit on her and pinched her during the shift and she got frustrated. DON stated, CNA 1 said she protected herself by holding Resident 1's hands down with her hands over the top of his. During an interview on 9/10/21, at 9:35 AM, with DON, DON stated, during her investigation interview with LVN 4, LVN 4 reported during CNA 1's shift on 9/8/21, CNA 1 told her Resident 1 had hit, pinched and spat at her for the last few hours and she (CNA 1) was on the verge of fighting back. DON stated, LVN 4 offered CNA 1 a break, CNA 1 declined, said she was ok. DON stated, CNA 1was allowed to continue to care for Resident 1. During an observation and interview on 9/10/21, at 10:23 AM, with LVN 2 and Assistant Director of Nursing (ADON), in Resident 1's room, Resident 1 was observed with purplish discoloration to the top of both hands and an abrasion to the inner wrist area. LVN 2 stated, on the day of the incident, he was told CNA 1 was having problems that day and cried in the break room before the incident happened. LVN 2 stated, staff should notify the boss or DSD when staff were crying and upset, and the staff should be given the option to go home. During an interview on 9/10/21, at 11:18 AM, with LVN 5, LVN 5 stated, when an employee was upset, they should be offered a break, sent home, or switched to a different assignment. During an interview on 11/12/21, at 6:10 AM, with LVN 1, LVN 1 stated, on 9/8/21, CNA 1 was assigned to Resident 1. LVN 1 stated, CNA 1 pushed Resident 1, in the geri chair, out of the staff break room. LVN 1 stated, CNA 1 said to Resident 1 "I'm done with you." LVN 1 stated, Resident 1 put his legs down on the side of the geri chair, as if he was going to stand as CNA 1 was about to walk away. LVN 1 stated, CNA 1 lifted Resident 1's legs straight up, Resident 1 went back into a laying position in the geri chair and CNA 1 walked away. LVN 1 stated, Resident 1 had purple bruises on his hands that he did not have before. LVN 1 stated, after further assessment Resident 1 was noted with bruising to both hands and an abrasion to his left wrist and right shoulder. LVN 1 stated, she could see something was wrong with Resident 1 because Resident 1 followed CNA 1 with his eyes, his demeanor changed, and he was very guarded when CNA 1 came out of the staff break room. LVN 1 stated, the facility regularly assigned CNA 1 to Resident 1. LVN 1 stated, Resident 1's behavior improved after CNA 1 no longer worked at the facility. During an interview on 11/12/21, at 6:34 AM, with LVN 3, LVN 3 stated, she translated for LVN 1 and Resident 1, after CNA 1 pushed Resident 1 out to the nurse's station. LVN 3 stated, Resident 1 was unable to state what happened. LVN 3 stated, she observed purple colored bruising to both the left and right hands of Resident 1. During an interview on 11/15/21, at 2:33 PM, with CNA 1, CNA 1 stated, on 9/8/21 she worked evening shift and the facility assigned her to Resident 1. CNA 1 stated, Resident 1 was very confused, non-weight bearing, very aggressive, and would hit, kick, spit, and scream. CNA 1 stated, she was left alone with Resident 1 during the whole shift. CNA 1 stated, Resident 1 was aggressive the whole time. CNA 1 stated, she took Resident 1 into the staff break room while she was on lunch because no one was helping her. CNA 1 stated, Resident 1 threw a blanket at her, tried to throw food at her, and caused her to become frustrated. CNA 1 stated, she kept Resident 1 from striking her by holding his hands. CNA 1 stated, she asked multiple co-workers for help and no one would help her. During an interview on 11/15/21, at 2:53 PM, with CNA 2, CNA 2 stated, on 9/8/21 she was working and heard CNA 1 "say a couple of things about being frustrated and heard her say I'm done." CNA 2 stated, she did not inform anyone of CNA 1's verbal statements of frustration. During an interview on 11/15/21, at 3:09 PM, with DSD, DSD stated, on 9/8/21 CNA 1 asked to leave work early. DSD stated, she had talked to CNA 1 about her excessive call-ins and history of leaving early. DSD stated, staff complained about CNA 1 taking off early and disappearing during her shift. DSD stated, when staff were aware that another staff was frustrated, staff were expected to talk to them, offer them time off, provide the phone number for the Employee Assistance Program and notify her (DSD). DSD stated, after the incident the nurse reported the comments CNA 1 had made prior to the incident. During a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention Program" dated 12/16, the P&P indicated, "Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. . .Protect our residents from abuse by anyone including. . .facility staff. . .Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior." During a review of the Lesson Plan titled, "Mandated Reporting," dated 6/15/21, the Lesson Plan indicated, "Course Objectives/Performance Standard. . .Participants will identify the signs of job stress. . .This includes short-temperedness. . .chronic absenteeism. . .. notice signs of feeling of being overwhelmed. . . when at work-prioritize ask for help. . .if feeling stressed reach out to supervisor or HR [human resources] for assistance." In violation of the above cited standards, the facility failed to ensure CNA 1 did not abuse Resident 1 when the facility allowed CNA 1 to continue to care for Resident 1 after CNA 1 verbalized her stress and frustration. This failure resulted in Resident 1 experiencing bruising, abrasions, pain and emotional distress. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and represents a class "A" citation.