Health inspection·September 27, 2024

Free from Abuse and Neglect CFR(s): 483.12(a)(1) §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; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to protect one of one sampled Resident (Resident 1) from abuse when Resident 1 was verbally abused by a Security Guard (SG). The facility's failure resulted in Resident 1 1. thinking and reliving the incident, 2. feeling sad 3. having low self-esteem 4. having no self-respect Findings: Resident 1 was admitted with multiple diagnoses including paraplegia (loss of inability to move the legs) and chronic pain (long-term pain). Review of Resident 1's record, titled "Minimum Data Set" (MDS is a standard assessment tool), dated 12/1/24, indicated his memory, reasoning abilities were intact. This was reflected in his Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive function [includes thinking, learning, and decision-making abilities]). Resident 1 scored 15 out of 15 indicating he had no cognitive impairment. Under functional abilities, Resident 1 was dependent (helper does all the effort, the resident does none of the effort to complete activity) to requiring substantia/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). A review of the recorded video sent from Resident 1's personal cellular phone, showed Security Guard 1 (SG 1) seated on the left facing Resident 1. SG 1 was heard saying disparaging remarks towards Resident 1, "You can't wipe your ass, telling him to jump, laughing at him, and saying you're gonna die here ..." Security Guard 2 seated on the right side, facing Resident 1 was observed laughing at some point during the phone recorded incident. The incident occurred in the unit lobby in front of the nurses' station and the unit elevator. During an interview on 4/18/24, at 10:02 AM, Resident 1 stated, "It happened on 4/13/24. It's like a slap in the face. I feel saddened. I have low self-esteem. They have no respect. I felt I need to take the video to take it seriously. I didn't say anything to staff. I kept thinking about it all day if I should say something. I don't want them not passing because of me." During an interview on 4/18/24, at 10:49 AM, Medical Doctor (MD) 1 stated that the video was horrible. During an interview on 4/18/24, at 11:49 AM, Licensed Social Worker 1 stated, "[Resident 1 named] showed me the video. I felt it was abuse. A lot of abuse of language, a lot of laughing at him. It was abusive. [Resident 1] was not happy with the security guard's presence, he does not like people in uniform, it reminded [Resident 1] of initial incident that landed him in the wheelchair." During an interview on 4/18/24, at 2:07 PM, the Nursing Director 1 stated, "Security guards are placed for the safety of the residents and staff. The security guards are another set of eyes." During an interview on 4/18/24, at 12:09 PM, Security Guard 3 stated that they were there to maintain a safe place, treat resident with respect, not to put a hand on any resident even if they get aggressive, and not to scream or say bad words towards the residents. A review of the facility Incident Interview Report dated 4/15/24, completed by Quality Management RN 2, indicated, Resident 1 stated, " ...Honestly, it made me sad. I was like man, is that how people see me." A review of the facility Incident Interview Report dated 4/15/24, completed by RN 2 indicated a Patient Care Assistant (PCA) 1 stated that Resident 1 showed the video and stated, " ... (SG 1) should not have interacted with (Resident 1) being so insulting. That's abuse. It was hard to watch. She was really provoking him ...He feels so insulted ..." A review of the Licensed Social Worker notes dated 4/15/24, indicated, " ... [Resident 1] expressed that the incident was very upsetting to him. There was a verbal exchange that he took a video of. In the exchange, [SG 1] laughed at him, called him names, made fun of his family and disability ...he kept closing his eyes and having difficulty focusing ..." A review of the facility Incident Interview Report dated 4/16/24, completed by QM RN 2 indicated, SG 2 stated, " ...I told her (SG 1) to stop. I told her to walk away and stop talking to [Resident 1]. Everyone is adult and I do not know what else I can say ..." When Resident 1 was asked, " ...Do you have any emotional distress or mental anguish? [Resident 1] did not reply but started crying ..." A review of the facility Investigation of Alleged Abuse dated 4/17/24 completed by Nurse Manager (NM) 1, indicated, " ...both security (SG) told the resident [Resident 1] that is why you can no longer wipe your ass; nobody gives a fuck about you; you are about to join your mother soon and that is why you are in a wheelchair. Both security guard were laughing and giggling ..." A review of the facility document, Department of Education and Training (DET) Checklist for evidence of contractor training of [facility name] Abuse and Neglect prevention program provided to SG 1 on 10/4/23, indicated, " ...persons working in [name of facility] under a contract ...are obligated under the law to refrain from acts of abuse ... The following summarizes what constitutes as abuse ...verbal (that is [i.e.] ...staff using inappropriate words towards a resident) ..." A review of the facility Policy and Procedure titled, "Abuse and Neglect Prevention, Identification, Investigation, Protection, Reporting and Response" dated 11/14/23, indicated, "[Facility name] shall promote an environment that enhances resident well-being and protects residents from abuse ...The employees, contractors, and volunteers shall provide a safe environment and protect residents from abuse ...Purpose: To protect resident from abuse ...Definition: ...verbal abuse means the use of oral ...or gestured communication that willfully includes disparaging and derogatory terms to residents ..." This violation had a direct or immediate relationship to the health, safety, or security of residents.