Health inspection·January 4, 2022

T22 72315 Nursing Service- Patient Care (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. 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. § 72527. Patients' Rights. (10) To be free from mental and physical abuse. F600 §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 facility failed to ensure Resident 1 was free from abuse when Activity Personnel (AP) 1 displayed verbally and physically abusive behavior towards Resident 1 when AP 1 yelled and used derogatory words to Resident 1, abruptly shook hard Resident 1’s wheelchair, and pulled Resident 1’s wheelchair out of the facility’s Recreation Room during activity on 6/18/2021. This deficient practice resulted in Resident 1 feeling upset, shaky and complained of pain on her back and hands because of the wheelchair being shook hard and pulled by AP 1. Findings: An unannounced visit to the facility was conducted to investigate a facility reported incident on 6/28/2021. A review of Resident 1's Admission Record indicated that the resident was a 66-year-old female, who was admitted at the facility on 1/26/2021, and readmitted on 2/28/2021, with diagnoses that included diabetes mellitus (disorder in which the blood sugar levels are too high) and muscle weakness. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 4/4/2021, indicated that Resident 1's cognitive (the ability to think, reason, and understand) level was intact. A review of Resident 1’s History and Physical dated 4/15/2021, indicated Resident 1 had the capacity to understand and make decisions. A review of a handwritten facility document titled “Interview Record” signed by the Administrator on 6/18/2021 timed at 3:05 PM, indicated “Per Resident 3, during Bingo game, two residents talking, AP 1 told them quiet, the two residents continue talking, AP 1 said Quiet and Shut up. Another resident (Resident 1) told AP 1 to shut up and AP 1 talk back and forth to Resident 1. AP 1 told her (Resident 1) he will be removed (Resident 1) from the room. AP 1 pull her (Resident 1) wheelchair hard in the middle of the Recreation Room and both of them talk in loud voice (sic).” A review of a handwritten facility document titled “Interview Record” conducted and signed by the Administrator, with Resident 1’s handwritten initials, on 6/22/2021, indicated “(AP 1) told them (two unnamed residents) QUIET!!! QUIET!!! in loud voice continue saying QUIET!!! QUIET!! QUIET!!! SHUT UP in loud voice, that time I jump in and I told him you SHUT UP. (AP 1) respond “WHAT THE HELL WITH YOU SHUT UP. We talk to each other back and forth in loud voice and then (AP) 1 walk behind me SHOCK my wheelchair very hard feeling my whole body JERKING. Few minutes I wheel myself out (sic).” A review of Resident 1’s Medication Administration Record (MAR) for 6/1/2021 to 6/30/2021 indicated that on 6/21/2021 at 2:03 PM, Resident 1 received two tablets of Acetaminophen (pain medication) 325 milligrams (mg) by mouth (for back pain) with a pain level of 4 (moderate pain which interferes significantly with daily living activities) over 10 (most severe or worst pain). A review of the facility's investigation report dated 6/22/2021, indicated that on 6/18/2021 AP 1 was running a Bingo game in the Recreation room with the residents when two residents (not identified) were talking. The investigation report indicated that AP 1 told the two residents to “hush” and when the two residents did not stop talking, AP 1 told them to “shut the hell up.” The investigation report indicated that Resident 1 informed AP 1 he cannot say that, when AP 1 proceeded to tell Resident 1 to shut up. The investigation report indicated that during Resident 1 and AP 1’s exchange of words, AP 1 pulled her wheelchair hard trying to escort her out of the Recreation Room. The investigation report indicated Resident 1 had to wheel herself back to the table and informed AP 1 he cannot wheel her out without permission. The investigation report indicated that Resident 1 was alert and oriented times four (oriented self, place, time, and situation). The investigation report indicated Resident 1 complained of back pain on 6/21/2021 due to the “wheelchair pulling.” During an interview on 6/28/2021, at 10:10 AM, AP 2 stated all activity personnel were reminded to respect all residents and always ask permission if they need to physically move them (from the Recreation Room). AP 2 stated Resident 1 was alert and oriented, and normally preferred things done immediately. AP 2 stated it was not right for AP 1 to tell Resident 1 to shut up in a rude manner and to move Resident 1’s wheelchair without asking permission. During an interview on 6/28/2021 at 10:43 AM., Resident 2 stated she heard AP 1 told Resident 1 to “shut up.” 2 stated it was not right for AP 1 or any facility staff to talk to residents like that. During an interview on 6/28/2021 at 11:22 AM, Resident 1 stated that during “Bingo” (on 6/18/2021) in the facility’s Activity Room, AP 1 was telling the other two residents (unable to remember specific residents) sitting behind her (Resident 1) to “shut up.” Resident 1 stated that AP 1 stated "hush" to the other two residents because they were talking in their own native language while AP 1 was calling out the Bingo numbers. Resident 1 stated that when the two residents did not stop and continued talking, AP 1 screamed “Shut up.” Resident 1 stated he interrupted AP 1 and informed AP 1 not to say shut up to the residents. Resident 1 stated that after that AP 1 told her "Shut the hell up or I will move you out!" Resident 1 stated she got very upset at AP 1. Resident 1 stated that AP 1 grabbed her wheelchair and moved it abruptly without her permission. Resident 1 stated she had to hold on to the wheelchair to try to stop it. Resident 1 stated it hurt her hands afterwards. Resident 1 stated her hands were shaky because she was so upset. Resident 1 stated it's not right for AP 1 to treat her like that. Resident 1 stated that the same night (6/18/2021), she was in so much pain (on her back) because of the abrupt movement of the wheelchair and trying to stop the wheelchair from moving. During an interview on 6/28/2021, at 12 PM, the facility’s Director of Nursing (DON) stated AP 1 was suspended on the same day of the incident (6/18/2021), and then terminated from the facility. The DON stated it was not right for any facility staff to treat residents without respect. A review of an undated facility policy and procedure titled "Abuse & Mistreatment of Residents, indicated that "Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents." The policy indicated," To uphold resident's right to be free from verbal, sexual, and mental abuse, corporal punishment (which is physical punishment, is used as a means to correct or control behavior) and involuntary seclusion." The facility failed to ensure Resident 1 was free from abuse when Activity Personnel (AP) 1 displayed verbally and physically abusive behavior towards Resident 1 when AP 1 yelled and used derogatory words to Resident 1, abruptly shook hard Resident 1’s wheelchair, and pulled Resident 1’s wheelchair out of the facility’s Recreation Room during activity on 6/18/2021. This deficient practice resulted in Resident 1 feeling upset, shaky and complained of pain on her back and hands because of the wheelchair being shook hard and pulled by AP 1. These violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient.