Health inspection·December 31, 2024

F557 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. § 72527. Patients' Rights. 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: (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. (16) To retain and use personal clothing and possessions as space permits, unless to do so would infringe upon the health, safety or rights of the patient or other patients. On 12/10/24, at 9:45 AM, an unannounced visit was made to conduct a facility reported incident regarding patient rights. The facility failed to ensure Patient 1 was treated with dignity and respect while being assisted by certified nurse assistant (CNA)1, by ensuring CNA 1 did not come in contact with Patient 1 after Patient 1 reported an incident that happened on 11/24/24, and reported the incident to the Administrator on 11/25/24. The Administrator then brought CNA 1 to Patient 1’s room on 11/25/24, to make CNA 1 apologize to Patient 1. As a result, Patient 1 verbalized feelings of being “embarrassed” and “upset,” and had the potential to place Patient 1 at risk for further abuse. A review of Patient 1’s Admission Record, the Admission Record indicated the facility admitted a 65 year old female Patient on 11/12/2022, with a diagnosis of diabetes (a disease that occurs when your blood sugar is too high) with diabetic neuropathy (a nerve problem that causes pain and numbness). A review of Patient 1’s Minimum Data Set (MDS- a patient assessment tool) dated 9/12/2024, the MDS indicated the patient’s cognition (mental processes) was intact. The MDS indicated Patient 1 required set up assistance (helper sets up, patient completes activity) with eating, oral hygiene, and personal hygiene. The MDS indicated Patient 1 required partial/moderate assistance (helper does less than half the effort) for upper body dressing. The MDS indicated Patient 1 required substantial/maximum assistance (helper does more than half the effort) with toileting hygiene, shower/bathing/ lower body dressing, and putting on/taking off footwear. A review of Patient 1’s Care Plan, titled, “Mood State,” dated 9/12/24, the care plan indicated to identify situations that might cause mood problem, and to monitor persistent mood. A review of Patient 1’s Care Plan, tilted “Self-Care Deficit,” revised on 9/30/24, the care plan indicated that Patient 1 was totally dependent on staff for all Activities of Daily living (ADL: task of everyday life). The Care plan indicated to provide assistance needed to the patient including continent care (the support and assistance provided to people who have bladder or bowel problems, or who are experiencing incontinence). A review of Patient 1’s Care Plan, tilted “Self-Care Deficit,” revised on 9/30/24, the care plan indicated that Patient 1 was totally dependent on staff for all Activities of Daily living (ADL: task of everyday life). The Care plan indicated to provide assistance needed to the patient including continent care (the support and assistance provided to people who have bladder or bowel problems, or who are experiencing incontinence). A review of Patient 1’s Care Plan, titled, “Behavioral Symptoms”, dated 10/4/24, the care plan indicated an approach to encourage Patient 1 to verbalize feelings and to provide support by allowing Patient 1 to express self, and to monitor for behavior. A review of Patient 1’s Physician Order, dated 11/21/24, the order indicated Patient 1 was COVID-19 positive, and required isolation (a set of infection control measures implemented to prevent the spread of infectious diseases from an infected patient to healthcare workers, visitors, and other patients. A review of Patient 1’s Care Plan, dated 11/25/24 and titled “Patient claims certified nurse assistant (CNA) made an inappropriate joke such as a CNA put hard boil egg to his private area,”, the care plan indicated the approach was for the administrator is to investigate, notify the police department, and notify department of health services. A review of Patient 1’s Progress Notes, dated 11/25/24 at 3:46 PM, the Progress Note indicated that Patient 1 verbalized to the ADM of being upset with CNA 1 regarding an inappropriate comment made by CNA 1 about a hard-boiled egg. The Note indicated the incident occurred on 11/24/24 and Patient 1 was assured by the ADM that the ADM would conduct an investigation, interview staff involved and any witnesses and take appropriate steps to protect patient rights. A review of Patient 1’s “Patient Interview Questions,” dated 11/25/24 to 11/28/24 conducted by the Administrator (ADM) and Director of Nursing (DON), the questions indicated questions that did not integrate or address monitoring of the psychosocial aspect, such as mood or behaviors of Patient 1, so Patient 1 could verbalize feelings and outcome as a result of the specific incident on 11/24/24. A review of the Nursing Assignments (Direct Care) dated 11/29/24 on the 3 PM to 11 PM shift, indicated CNA1 was assigned to take care of Patient 1. During an interview with Patient 1 on 12/10/24 at 9:55 AM, Patient 1 stated CNA 1 refused to give Patient 1 a fresh gown or change Patient 1’s brief (diaper) when Patient 1 requested. Patient 1 stated on one occasion on 11/24/24, Patient 1 hurried to her meal tray as the meal tray arrived, and CNA 1 stated loudly, can’t you wait for me to bring your food? This is not a one –to- one (individualized care to a patient) facility, you are not the only one I am assigned to!” Patient 1 stated CNA 1 told Patient 1 “you should be lucky” CNA 1 “agreed to take this assignment, and that no one wants this room.” Patient 1 stated “crying a lot” since being told by CNA1 that facility staff did not want to assist Patient 1. During this same interview, Patient 1 stated on that same incident, on 11/24/24, when her meal tray arrived, there was a hard-boiled egg on the meal tray. Patient 1 stated her hard-boiled egg rolled off the tray and landed on Patient 1’s bed. After the egg was placed back on the meal tray by CNA 1, Patient 1 stated CNA 1 repositioned Patient 1 in bed, and then the egg rolled off the meal tray again, but this time onto the floor. Patient 1 stated when CNA 1 picked up the egg from the floor, CNA 1 held the egg in front of the area of CNA 1’s “genital area” and CNA 1 asked Patient 1 what to do with the egg that landed on the floor. Patient 1 stated feeling the comment that CNA 1 made regarding the egg and holding it in front of his genital area made Patient 1 feel “disrespected to be treated this way”, embarrassed and afraid.” Patient 1 stated reporting the incident on 11/25/24 to the Administrator (ADM). Patient 1 stated not reporting the facility staff on 11/24/24, the day the incident occurred, since she was “afraid” because the ADM and the DON were not in the facility. Patient 1 stated after reporting the incident to the ADM, "no one came to speak to me regarding my feelings or preferences or addressed any concerns I had regarding CNA 1. During the same interview on 12/10/24 at 9:55 AM with Patient 1, Patient 1 stated after the incident on 11/24/24, CNA 1 came into Patient 1’s room to obtain Patient 1’s blood pressure and blood sugar, which Patient 1 stated was “strange.” During an interview on 12/10/24 at 10:29 AM with the Administrator (ADM), the ADM stated conducting an interview with CNA 1 regarding the incident on 11/24/24 between Patient 1 and CNA 1 in Patient 1’s room. The ADM stated CNA 1 told Patient 1 that “no one wanted to go in this room to accept the assignment” only because Patient 1 was on isolation precaution (a set of infection control measures implemented to prevent the spread of infectious diseases from an infected patient to healthcare workers, visitors, and other patients), due to Patient 1 being positive for Coronavirus 2019 (COVID-19: respiratory illness). The ADM stated after the incident between Patient 1 and CNA 1, the ADM did not discuss with licensed nurses (LN) to conduct any follow up monitoring on Patient 1, or to evaluate Patient 1’s mood or behaviors. During an interview on 12/10/24 at 11 AM with Patient 1, Patient 1 stated the ADM had not followed up with Patient 1 on how Patient 1 felt after the incident between her and CNA 1 on 11/24/24. Patient 1 stated facility staff did not ask Patient 1 about her feelings regarding the incident, or towards CNA 1. Patient 1 stated not wanting CNA 1 to be assigned to her, and that Patient 1 was “upset.” During an interview with on 12/10/24 at 11:10AM with CNA 1, CNA 1 stated telling Patient 1 that everyone in the facility was scared to be assigned to Patient 1’s room, since the patient was COVID-19 positive. CNA 1 stated that Patient 1 rushes CNA 1, so CNA 1 stated telling Patient 1 that she was not his only patient in the facility, and not the only patient that CNA 1 was assigned to. CNA 1 stated a few days after the incident on 11/24/24, CNA 1 assisted licensed vocational nurse (LVN) 1 to obtain Patient 1’s blood pressure and blood sugar. During an interview on 12/10/24 at 1:30 PM with the ADM, the ADM stated not conducting an in service to licensed nurses regarding abuse after the 11/24/24 incident between Patient 1 and CNA 1. The ADM stated not informing LN’s to monitor Patient 1 for depression or sadness or any other changes in mood or behaviors after Patient 1 verbalized the alleged abuse from CNA 1. A review of the facility’s policy and procedure (P&P) titled, “Quality of life- Dignity,” undated, the P&P indicated each patient shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Patients are to be treated with dignity and respect at all times. The facility culture was one that supports and encourages humanization and individuation of patients, and honors patient choices, preferences, values, and beliefs. The P&P indicated that staff would speak respectfully to patient at all times, including addressing the patient by his or her name of choice and not “labeling” or referring to the patient by his or her room number, diagnosis, or care needs. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist patient by promptly responding to a patient’s request for toileting assistance. A review of the facility’s undated P&P, titled “Abuse Prevention Program,” the P&P indicated to investigate and report any allegations of abuse, and to protect patients during the abuse investigations. The P&P indicated to identify and assess all possible incidents of abuse. The P&P indicated to implement changes to prevent future occurrences of abuse. A review of the facility’s policy and procedure (P&P) titled, “Abuse, Neglect, & Exploitation Prohibition” dated 12/1/18, the P&P indicated the purpose of the P&P was for each patient to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The P&P indicated for staff to integrate monitoring of staff and patients which were indicative of high stress levels that may lead to abuse. The P&P indicated that the facility would conduct an investigation of any alleged abuse and would investigate all patterns, trends or incidents that suggest the possible presence of abuse. The P&P indicated that the facility would protect patients from harm during the investigation and to ensure protection of the patient. The facility failed to ensure Patient 1 was treated with dignity and respect while being assisted by certified nurse assistant (CNA)1, by ensuring CNA 1 did not come in contact with Patient 1 after Patient 1 reported an incident that happened on 11/24/24, and reported the incident to the Administrator on 11/25/24. The Administrator then brought CNA 1 to Patient 1’s room on 11/25/24, to make CNA 1 apologize to Patient 1. As a result, Patient 1 verbalized feelings of being “embarrassed” and “upset,” and had the potential to place Patient 1 at risk for further abuse. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.