Other·April 25, 2023

On 3/29/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about staff to resident abuse. The facility failed to protect the resident's right to be free from mental abuse and verbal abuse by Certified Nursing Assistant 1 (CNA 1) for Resident 1. This deficient practice resulted in Resident 1 feeling uncomfortable. A review of Resident 1's Admission Record indicate the facility admitted Resident 1 admitted on 5/18/2022 with diagnoses including hypertensive urgency (elevation in blood pressure), coronary angioplasty (a procedure used to widened blocked or narrowed coronary arteries ), cardiac arrest (sudden, unexpected loss of heart function ), muscle weakness, epilepsy (a disorder in which nerve cell activity in the brain is disturbed ), right bundle branch block ( a condition in which there is a delay or blockage along the pathway that electrical impulses travel to make the heart beat), difficulty walking, major depressive disorder (a mental health disorder characterized by persistently depressed mood) A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 2/16/2023 indicated Resident 1 had intact cognition and required extensive-one-person physical assist with bed mobility, dressing, eating, toilet use, and personal hygiene. During an interview on 3/15/2023 at 1 PM, Resident 1 stated a Certified Nurse Assistant 1 (CNA 1) who works 3 pm to 11 pm shift, refused to give her [Resident1] snacks that a family brought for Resident 1. Resident 1 stated the CNA told Resident 1 she did not need to eat the snacks because Resident 1 "is getting too fat. "Resident 1 stated CNA 2's statement made her [Resident 1] feel uncomfortable. Resident 1 stated she reported CNA 1 to CNA 2. During an interview on 3/15/2023 at 1:15 PM, CNA 2 stated, Resident 1 reported to her that "the afternoon nurse does not give her snacks because she [Resident 1] is too fat and needs to lose weight. "CNA 2 stated she reported this allegation to Licensed Vocational Nurse (LVN 1) two week ago and was not sure if the abuse coordinator was notified. During an interview on 3/15/2023 at 1:20 PM, LVN 1 stated, CNA 2 informed her about two weeks ago that Resident 1 reported that "the afternoon nurse does not give the resident her [Resident 1] snacks and tells the resident [Resident 1] that she [Resident 1] is too fat. " . LVN 1 stated nurses are supposed to provide residents with their [residents] snacks. LVN 1 stated, "making remarks about a resident's weight is unacceptable. " During an interview on 3/15/23 at 1:30 PM, the Social Worker (SW) stated Resident 1 told her that a nurse who works the 3 pm-11 pm shift withholds Resident 1's snacks and tells Resident 1 "Your butt (buttocks) is getting too big. "The SW stated, "that the nurse is getting too comfortable. This behavior is not acceptable." During a record review of Resident 1's Progress Notes dated 3/15/2023 timed at 5:01 PM, indicated the Department of Public Health informed the Social Services during the writer's unannounced visit to the facility. The progress notes indicated Resident 1 informed the writer that a CNA did not give Resident 1 her [Resident1] snacks because of Resident 1's weight. The progress notes indicated Resident 1 told the Social Services and Social Services Assistant that "she asked her Certified Nurse Assistant to hand her snack by the bedside and the CNA stated, "No because your butt is too big." A review of the facility's policy and procedures titled, "Abuse Prohibition Policy and Procedure," dated 2/23/2021, indicated Healthcare Centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. Mental abuse includes, but not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur through either verbal or non-verbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation, or degradation. The facility failed to protect the resident's right to be free from mental abuse and verbal abuse by CNA 1 for Resident 1. This deficient practice resulted in Resident 1 feeling uncomfortable. The above violations had a direct relationship to the health, safety, and security of all residents in the facility.