Other·November 13, 2023

42 CFR §483.21: Services Provided Meet Professional Standards §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. 42 CFR §483.12: Freedom from Abuse, Neglect, and Exploitation §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 §72523: Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 9/29/2023 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident rights to be free from abuse. The facility failed to protect Resident 1's right to be free from physical and mental abuse (willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish) in accordance with facility's policy and procedures (P&P) titled, "Resident Rights Under Federal Law" revised 3/1/2023, and "Abuse Prohibition" revised on 10/24/2022, when: 1. On 7/6/2023 at 4:33 a.m., Licensed Vocational Nurse 1 (LVN 1), Certified Nursing Assistants 1 and 2 (CNA 1 and CNA 2), held Resident 1's arms and legs, and spread Resident 1's legs against the resident's wishes and after Resident 1 screamed at LVN 1, CNA 1 and CNA 2 to "stop" when LVN 1 inserted a straight catheter (a flexible tube placed in the bladder [body organ that stores urine] to obtain urine) into Resident 1's bladder and collected Resident 1's urine sample. 2. LVN 1 did not obtain Resident 1's consent before collecting a urine sample using a straight catheter from Resident 1. 3. LVN 1 did not explain straight catheterization (the process of draining urine by use of catheter) procedure to Resident 1. 4. The facility subjected Resident 1, Resident 2, and Resident 3 to an invasive (enter a person's body by a needle, tube, device, or scope) procedure without a physician's order/approval and not in accordance with the facility's P&P titled, "Procedure Specimen (sample) Collection: Urine", revised on 2/1/2023, P&P titled, "Physician Advanced Practice Provider (APP) Orders" revised 3/1/2022, and P&P titled, "Catheter: Urinary -Justification for Use", revised on 8/7/2023. 5. LVN 1 and unknown facility's licensed staff did not document that Resident 1, Resident 2, and Resident 3 were straight catheterized to obtain urine sample for urinalysis ((UA), medical test in which the urine is examined to diagnose and monitor various illnesses) with culture and sensitivity (( C&S) a urine test to find the germs that can cause the infection and check what kind of medicine will work best for the infection) in accordance with the facility's P&P titled, "Clinical Record: Charting and Documentation", revised on 2/1/2023. Resident 1 stated she felt scared, experienced pain in her private parts, suffered mental anguish, emotional distress and stated, "I felt raped". Resident 1 developed shingles (a highly infectious painful skin rash and fluid -filled blister [raised area on the skin]) in the right side of the face and was sent out to general acute hospital 1 (GACH 1) on 7/19/2023 for evaluation and treatment. Resident 1 stated she was traumatized and experienced excruciating pain in her private parts during the straight catheterization. Resident 2 stated he felt pain during the catheterization and did not want to have a straight catheter again. Resident 3 potentially experienced excruciating pain in her private parts. Resident 3 was non interviewable. 1. A review of Resident 1's Admission Record indicated the facility admitted Resident 1, a 88-year-old female, on 2/16/2022 with diagnoses including heart failure (the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), generalized muscle weakness and abnormalities of gait and mobility. A review of Resident 1's untitled Care Plan created on 12/29/2022 indicated Resident 1 had a Physician Orders for Life-Sustaining Treatment ((POLST), written medical order that helps give people with serious illness more control over their own care by specifying the types of medical treatment they want to receive during serious illness). The goal of the care plan indicated the resident, or their healthcare decision maker shall participate in decisions regarding medical care and treatment. The interventions included to inform the resident and/or healthcare decision maker of any change in status or care needs, promote opportunities for resident/healthcare decision maker to participate in decisions regarding care and to provide the resident/healthcare decision maker with sufficient information to make an informed decision (a choice made after learning about the options, potential outcomes, benefits, and risks). A review of Resident 1's Minimum Data Set ((MDS), standardized care and health screening tool) dated 7/4/2023 indicated Resident 1 was cognitively (ability to think and make decisions) intact. Resident 1 needed supervision (oversight, encouragement or cuing) with bed mobility, transfer, eating, toilet use, personal hygiene, and limited assistance (resident highly involved with activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) with dressing and bathing. The same MDS indicated Resident 1 was occasionally incontinent of urine. A review of Resident 1's Physician Order dated 7/5/2023 at 8:38 p.m., indicated a telephone order to collect urine sample for UA with C&S for urinary frequency (need to pass urine more often than normal). A review of Resident 1's Laboratory (Lab) Results Report indicated Resident 1's urine sample was collected on 7/6/2023 at 4:33 a.m. A review of Resident 1's Situation, Background, Appearance, Review and Notify (SBAR, tool that allows healthcare team members to provide essential and concise information about the individual's condition) Communication Form and Progress Notes dated 7/19/2023 at 9 a.m., indicated Resident 1 reported abuse allegation to the DSD. Resident 1 reported that on 7/6/2023, she was pinned down while LVN 1 was inserting a catheter. The SBAR indicated Resident 1 was in emotional distress. The same SBAR also indicated Resident 1 had a red rash on the forehead and that the NP gave order to transfer Resident 1 to GACH 1 for evaluation of the rash. A review of GACH 1 "After Visit Summary" dated 7/19/2023, indicated Resident 1's rash was diagnosed as Herpes zoster keratitis and was given a physician order to take Valacyclovir one gm one tablet by mouth three times a day for 10 days. The After Visit Summary indicated "shingles infection is common in people which included those who are experiencing a lot of stress." A review of Resident 1's Progress Notes dated 7/20/2023 at 1 a.m., indicated Resident 1 returned to the facility from GACH 1 on 7/20/2023. A review of the facility's Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their clients) Notes dated 7/20/2023 at 3:33 p.m., indicated the IDT held a conference meeting with Resident 1's NOK. The IDT informed Resident 1's NOK that Resident 1 reported that three employees, LVN 1, CNA 1, and CNA 2, held her down during the collection of the urine sample during early morning between 7/5/2023 and 7/6/2023. Resident 1 reported the incident to the facility on 7/19/2023. A review of the facility's Final Investigation Summary Report dated 7/24/2023, indicated that on 7/5/2023 at about 4:45 a.m., LVN 1 to collect urine using a bedpan (a device placed underneath a person to pass urine and or stool) sample and to comply with a physician's order for Resident 1. LVN 1 explained to Resident 1 that LVN 1 will have to do catheterization after Resident 1 did not void (pass urine) in the bedpan. LVN sought the help of CNA 1 and CNA 2. CNA 1 held on to Resident 1's knees with her right hand. CNA 2 held Resident 1's folded forearms to immobilize Resident 1 ... "Urine collection took less than five minutes. LVN 1 acted in good faith in trying to obtain a urine sample and proceeded with catheterization ...". A review of Resident 1's Psychologist Notes dated 7/26/2023, indicated Resident 1 was cognitively intact and was able to articulate feelings. Resident 1 was anxious and sad, teary at times during the consultation. 2. A review of Resident 2's Admission Record indicated the facility admitted Resident 2, a 58-year-old male, on 8/14/2023 with diagnoses including cerebral infarction (condition caused by interruption or blockage of blood flow to the brain) and abnormal posture. A review of Resident 2's MDS dated 8/18/2023, indicated Resident 2 had impaired cognition. Resident 2 needed one-person physical assistance with bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. The same MDS indicated Resident 2 was always incontinent of urine. A review of Resident 2's Physician Order dated 9/19/2023 at 4:10 p.m., indicated to obtain urine for UA and C&S. A review of Resident 2's Lab Result dated 9/21/2023, indicated a urine sample collection time of 4:50 a.m. During an interview with Resident 2 on 10/5/2023 at 1:09 p.m., Resident 2 stated the facility collected his urine sample " ...last month [9/2023]" using a catheter. Resident 2 stated, "The nurse explained to him that the urine will be collected by catheter". Resident 2 stated he experienced pain level eight out of 10 pain level (8/10 numerical tool to assess pain where zero is no pain and 10 is severe pain). Resident 2 stated he felt excruciating pain during the procedure, and "1 do not want it done again because it hurts". 3. A review of Resident 3's Admission Record indicated the facility admitted Resident 3, a 95-year-old female, on 1/19/2017 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and muscle weakness. During a review of the MDS dated 7/25/2023 indicated Resident 3 had severely impaired cognitive skills for daily decision making. Resident 3 needed one-person physical assistance with bed mobility, dressing, eating, toilet use, personal hygiene and two and more person physical assistance with transfer and bathing. The same MDS indicated Resident 3 was always incontinent of urine. During a review of the facility's "Nursing Staffing Assignment and Sign in Sheet" dated 9/20/2023, indicated LVN 1 worked on 9/20/2023 on the 11 p.m. to 7 a.m. shift. During a review of the SBAR Communication Form and Progress Notes dated 10/4/2023, indicated the director of nursing (DON) documented there was a physician's order dated 9/20/2023 to collect Resident 3's urine sample. During a review of Resident 3's lab report dated 9/21/2023, indicated the facility collected Resident 3's urine on 9/21/2023 at 4:37 a.m. During an interview and record review with LVN 2 on 9/29/2023 at 8:31 a.m., Resident 1's physician order and the nurses progress notes. LVN 2 stated a physician order was needed to collect a urine sample using the straight catheter for Resident 1. LVN 2 stated she was unable to find a physician's order to collect the urine sample using a straight catheter. LVN 2 also stated she was unable to find any documentation that supported LVN 1 had explained to Resident 1 about an order to obtain a urine sample by straight catheter and that Resident 1 had consented for LVN 1 to insert a straight catheter to collect the urine sample. During an interview with DSD on 9/29/2023 at 10:34 a.m., DSD stated that on 7/19/2023, Resident 1 reported to DSD that LVN 1 came in the middle of the night on 7/6/2023, awakened Resident 1 and informed Resident 1 that LVN 1 needed a urine sample. DSD stated LVN 1 then proceeded to collect the urine sample by using a straight catheter. DSD stated LVN 1 called CNA 1 to help hold Resident 1's legs because LVN 1, "may have a hard time inserting the straight catheter" in Resident 1. DSD stated LVN 1 also called CNA 2 to help hold Resident 1's arms while LVN 1 inserted a straight catheter in Resident 1. During a telephone interview with LVN 1 on 9/29/2023 at 11:34 a.m., LVN 1 stated on 7/5/2023 she received an order from Resident 1's primary physician to collect urine sample from Resident 1. LVN 1 then stated she did not obtain a physician order to collect the urine sample using a straight catheter. LVN 1 stated before she collected the urine sample on 7/6/2023, she explained to Resident 1 that she will collect a urine sample using straight catheter. LVN 1 stated "Resident 1 did not say yes or no" to the procedure. LVN 1 stated she inserted a straight catheter in Resident 1 and collected Resident 1's urine with the help of CNA 1 and CNA 2. LVN 1 stated she did not document that she explained the urine collection procedure to Resident 1 and that Resident 1 did not struggle or say "no" during the procedure. LVN 1 stated the collection of Resident 1's urine by straight catheter was "done quickly." LVN 1 further stated "I did not document the procedure of collecting the urine sample in the nurses' notes. LVN 1 stated it is important to document to ensure good communication among staff." During an interview with CNA 1 on 9/29/2023 at 11:58 a.m., CNA 1 stated that on 7/6/2023 between 4 a.m. and 5 a.m., LVN 1 called CNA 1 to help LVN 1 collect urine sample from Resident 1. CNA 1 stated she came to help LVN 1, stood at the end of the bed and held on Resident 1's legs. CNA 1 stated she was just "touching" Resident 1's legs and did not "pin her down". CNA 1 further stated CNA 2 was touching Resident 1's arms during the insertion of the straight catheter. During an interview on 9/29/2023 at 12:17 p.m., ADM stated the incident with Resident 1 happened on 7/6/2023 and that Resident 1 reported the incident to the facility on 7/19/2023. The ADM stated the procedure of collecting the urine sample was explained to Resident 1, however, the ADM agreed and stated the facility was not able to find any documented evidence that the procedure of collecting urine by straight catheter was explained to Resident 1 and that Resident 1 consented to collecting urine using a straight catheter. During an interview with the director of nursing (DON) on 9/29/2023 at 12:29 p.m., the DON stated collecting urine sample by straight catheter required a physician's order because the procedure was invasive, and that the physician must be aware of the procedure. During an interview with Resident 1 and NOK 1 in the MDS office on 9/29/23 at 12:45 p.m., Resident 1 stated that, "On 7/6/23 at 4:30 a.m., I was restrained by three nurses. The nurse told me I must give urine sample for the laboratory test. I was half asleep and I said to myself, what are they doing to my body. The three of them held my arms and legs, they spread my legs and put something sharp in my private parts and I suffered excruciating pain. I can't explain the pain. I was laying there in pain and I was suffering. I was traumatized. I told them to stop, I cried, I screamed, they did not stop. No one came to help me. They should have told me in advance. They just came into my room ...and I feel like am not treated as a human being. I am 88 years old and 100 pounds. They could have waited later during the day. I kept quiet and did not tell anyone because I feared retaliation, I was always thinking about it, it is in my mind, I was scared. I did not give them permission to do this. I must have told someone, and the administrator came and interviewed me. This is serious, all I want is justice. I want compensation for my pain and suffering, my brain was affected. I got shingles and my