Health inspection·September 3, 2021

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. § 72315(b) (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. On 9/25/2018, the Department received a Facility Reported Incident (FRI) regarding Certified Nurse Assistant 1 (CNA 1) covering Resident 1’s mouth with her hand while wearing a dirty glove during adult brief change. On 10/10/2018, an unannounced visit was conducted at the facility. The facility failed to: 1. Failure to ensure Resident 1 was free from physical abuse. 2. Failure to ensure Resident 1 was treated with dignity and respect. As a result, Resident 1 who was a 94-year-old-female, was rough handling from Certified Nursing Assistant 1 (CNA 1), who was observed by CNAs 2 and 3 firmly holding Resident 1’s face with a soiled rubber glove while providing care to Resident 1. During a review of Resident 1’s Admission Record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on 8/28/2015. Resident 1’s diagnoses included unspecified dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) without behavioral disturbance, and Alzheimer’s disease (mental deterioration with impairment such as memory loss and judgment). During a review of Resident 1’s Minimum Data Set (MDS), a resident assessment and care screening tool, dated 9/7/2018, the MDS indicated Resident 1 had cognitive (thought process) problems, impaired decision-making, and was sometimes able to make needs known and sometimes able to understand others. According to the MDS, Resident 1 required extensive assistance of one-person physical assist with bed mobility, transferring, locomotion on and off the unit, and with eating and personal hygiene. During a review of Resident 1's care plan titled, “Activities of Daily Living (ADLs [self-care activities such as eating, personal hygiene, dressing, and bathing]), dated 6/8/2018, the care plan indicated Resident 1 required assistance in activities of daily living including personal hygiene, dressing, and bathing related to dementia and Alzheimer’s disease. The goal was for Resident 1 to be able to maintain dignity and self-esteem. The staffs’ interventions were to encourage independent functions by providing cues, assist in ADLs, explain the task prior to starting the task, use adequate assistance during care, promote dignity and handle gently when giving care. During a review of Resident 1’s Nursing Progress Notes (NPN), dated 9/22/2018 and timed at 8:18 a.m., the NPN indicated on 9/22/2018 at approximately 5:50 a.m. while changing Resident 1 adult brief (diaper), Resident 1 became agitated, kicking, screaming, and scratched CNA 1 on the face. During an interview on 10/10/2018 at 10:22 a.m., the Administrator (ADM) stated he was informed during the overnight shift 11 p.m. to 7 a.m. on 9/22/2018, CNA 1 rough handled Resident 1. The ADM stated CNA 1 was no longer an employee at the facility. During an interview on 10/10/2018 at 11:40 a.m., CNA 2 stated during the shift he was assigned to provide care for Resident 1. CNA 2 stated Resident 1 was mildly agitated, and he requested help from another coworker to clean Resident 1. CNA 2 stated CNA 3 assisted him (CNA 2) to clean and change Resident 1’s adult brief. CNA 2 stated CNA 1 also volunteered to assist with Resident 1’s care because she CNA 1 had a good relationship with the resident. CNA 2 stated during care, CNA 1 grabbed Resident 1’s face to tell her, “Calm Down” because Resident 1 was resistant to care. CNA 2 stated CNA 3 moved CNA 1’s hand away from Resident 1’s face and asked CNA 1 to leave the room. During an interview on 10/10/2018 at 12:45 p.m., CNA 3 stated CNA 2 asked for assistance to change Resident 1’s adult brief. CNA 3 stated Resident 1 was agitated and was screaming, and not cooperative with her care. CNA 3 stated CNA 1 came into Resident 1’s room and helped change the resident. CNA 3 stated while putting on gown and an adult brief for Resident 1, CNA 1 turned the resident aggressively to get the brief on her and firmly grabbed Resident 1’s face with a soiled rubber glove on her hand and squeezed Resident 1’s cheeks together. CNA 3 stated she pulled CNA 1’s hand away from Resident 1’s face and said, “No! That is not ok.” CNA 3 stated CNA 1 laughed and walked out of Resident 1’s room, and they (CNA 2 and CNA 3) finished changing Resident 1. During an interview on 10/11/2018 at 11:03 a.m., Registered Nursing supervisor (RN 1) stated Resident 1 was screaming while CNAs 1, 2, and 3 were changing her adult brief. RN 1 stated Resident 1 was screaming so loudly it prompted RN 1 to check on the resident, upon entering the room, CNAs 1, 2, and 3 were almost finished with Resident 1’s care. RN 1 stated CNA 3 reported the incident a few minutes later. RN 1 stated she interviewed CNA 1 about holding Resident 1’s face and CNA 1 acknowledged holding her face to help her calm down. RN 1 stated the incident was reported to the facility’s Administrator (ADM) right away and an incident report was completed. During a review of the facility’s Abuse Investigation Reporting form, dated 9/22/2018, the report indicated Resident 1 was deemed by her physician as not having the capacity to understand and make decisions and physically needs total assistance to perform ADLs. The Abuse Investigation Reporting form indicated CNA 1’s employment was terminated due to CNA 1 confirming holding Resident 1 by the mouth and telling the resident to calm down. The abuse investigation reporting indicated CNA 1’s actions were considered reasonably unnecessary and inappropriate. During a review of the facility’s policy and procedures (P/P) titled, “Preventing Resident Abuse,” revised on 9/1/2016 indicated the facility’s goal was to achieve and maintain an abuse free environment. The abuse prevention/ intervention program includes but is not limited to assisting or rotating staff working with difficult or abusive residents. Helping staff to deal appropriately with stress and emotions. Training staff to understand and manage a resident’s verbal or physical aggression. Monitoring staff on all shifts to identify inappropriate behaviors toward residents such as using derogatory language, rough handling of residents, and ignoring residents while giving care. Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues. Encouraging all personnel, residents, family members, visitors to report any signs of suspected incidents of abuse to facility management immediately. During a review of the facility’s “Notice to Employee Change of Relationship” dated 9/25/2018 indicated effective 9/25/2018 CNA 1’s employment was terminated due to holding Resident 1’s mouth, squeezing her cheeks together as intervention to calm down resident and was considered unnecessary and inappropriate. During a review of the facility’s P/P titled, “Abuse Prevention and Prohibition Program” dated 1/1/2017, the P/P indicated each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. The facility failed to: 1. Failure to ensure Resident 1 was free from physical abuse. 2. Failure to ensure Resident 1 was treated with dignity and respect. As a result, Resident 1 who was a 94-year-old-female, was rough handling from Certified Nursing Assistant 1 (CNA 1), who was observed by CNAs 2 and 3 firmly holding Resident 1’s face with a soiled rubber glove while providing care to Resident 1. These violations presented a direct or immediate relationship to the health, safety, security, or welfare of Resident 1.