Other·October 29, 2021

F 600 G §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; 22 CCR § 72315 (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22 CCR § 72527 (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. The facility failed to follow the aforementioned regulation by failing to keep Resident 1 free from neglect when Resident 1's call light was not within his reach for an hour. This failure prevented Resident 1 from notifying staff he needed suctioning to remove excess saliva, which caused Resident 1 physical and emotional distress and potentially contributed to a three-day hospitalization for treatment of pneumonia (a lung infection which results in a build-up of fluid in the lungs and causes difficulty breathing). A review of Resident 1's Face Sheet indicated Resident 1 was admitted to the facility in July 2020, with a diagnosis of right renal nephrectomy (right kidney removal) for a mass. A review of the Minimum Data Set (MDS, an assessment tool used to guide care), dated 4/19/21, indicated Resident 1 had multiple sclerosis (a disorder of the brain and spinal cord). The MDS indicated Resident 1 was unable to move both sides of his upper and lower extremities and was totally dependent on assistance from one staff member for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 1 had a Brief Interview for Mental Status score of 15. (The Brief Interview for Mental Status, BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) During an interview on 4/27/21 at 11:00 a.m., Resident 1 spoke in a voice slightly louder than a whisper and stated he had filed a police report after he was sent to the hospital. Resident 1 stated he filed the report because he had used his air blow call light (a hands-free method used to activate a call light by blowing through a tube) to get assistance from staff because he felt like he was "choking on his saliva." Resident 1 stated Certified Nursing Assistant 1 (CNA 1) came into the room, turned off the call light, moved the air blow call light out of Resident 1's reach and never asked what Resident 1 wanted and did not attend to his needs before CNA 1 left the room. Resident 1 stated he was upset and anxious as he "struggled" to reach the air blow call light. During a concurrent observation on 4/27/21 at 11:00 a.m., in Resident 1's room, Resident 1 blew into his air blow call light. When the call light was activated, a light was visible outside the resident's room above the door, and an audible alarm rang. A review of Resident 1's IDT (Interdisciplinary Team) Conference notes dated 4/6/21 at 10:01 a.m., indicated, "[Resident 1] expressed a concern while at the acute hospital on 4/1/21 indicating that his call light was turned off by the staff. He asked the nurse to call the sheriff and report his concern." During an interview on 5/4/21 at 3:50 p.m., with CNA 1, CNA 1 stated he was assigned as the certified nursing assistant for Resident 1 on 3/31/21 during the evening shift (3 p.m. to 11:30 p.m.). CNA 1 stated the last time he saw Resident 1 that evening shift was at 10:30 p.m. CNA 1 stated at 11:10 p.m. the call light was on for the room shared by Resident 1 and Resident 2. CNA 1 stated he entered the shared room and went to Resident 2's bedside, but Resident 2 said he had turned on his call light for Resident 1. CNA 1 stated he turned off the television and left the room because Resident 1 had not asked for anything more. During an interview on 5/4/21 at 3:35 p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she had been assigned to Resident 1 on 3/31/21 for the night shift (11 p.m. in the evening until 7:30 a.m. the next day). CNA 2 stated at the start of her shift on 3/31/21 at 11 p.m., she noticed Resident 1's call light was on and heard the call light's ring. She stated she told CNA 1 that Resident 1's call light was on and asked him to answer Resident 1's call light because she was busy with another resident. CNA 2 stated she noticed at 11:15 p.m., that Resident 1's call light was still on. CNA 2 stated she went into Resident 1's room to answer his call light and saw Resident 1 crying, with his air blow call light outside his reach. CNA 2 stated Resident 1 said he had been trying to call for assistance for an hour but had been ignored. During an interview on 7/7/21 at 8:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he had worked the 3/31/21 night shift. LVN 1 stated he noticed when he started his shift at 11:00 p.m., that the call light and audible alarm were activated for Resident 1's room. LVN 1 stated between 11:10 p.m. and 11:15 p.m., CNA 2 called him to Resident 1's room to assess Resident 1. LVN 1 stated Resident 1 told him Resident 1 had been trying to call someone for 30-60 minutes because he had been having difficulty breathing. LVN 1 stated he checked Resident 1's oxygen saturation (a measurement of oxygen in the blood expressed as a percentage, with 100 percent the maximum amount of oxygen possible), and found a low oxygen saturation reading of 90%. LVN 1 stated Resident 1 was sent to the hospital between 2 a.m. and 3 a.m. because of continued low oxygen saturation. A review of Resident 1's acute care hospital, Emergency Department Provider Note, date of service 4/1/21 at 3:55 a.m., indicated Resident 1 entered the emergency department with shortness of breath; a heart rate of 123 beats per minute (normal range of 60 to 100 beats per minute); respirations of 28 breaths per minute (normal range of 12 to 16 breaths per minute); and an oxygen saturation of 85% (normal range of 95% - 100%). A review of Resident 1's acute care hospital, Hospitalists' SNF/Rehab Discharge Summary, dated 4/3/21, indicated Resident 1 was admitted to the hospital on 4/1/21, with a diagnosis of acute respiratory failure (sudden onset of difficulty breathing, usually the result of a disease or injury effecting the lungs' ability to provide enough oxygen and/or remove enough carbon dioxide for the body's needs) and pneumonia, and was discharged on 4/3/21. Therefore, the facility failed to keep Resident 1 free from neglect when Resident 1's call light was not within his reach for an hour, which prevented Resident 1 from asking for suctioning, causing both physical and emotional distress.