Health inspection·December 10, 2021

§ 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. § 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 4/16/18, the Department received a facility reported incident (FRI) indicating Patient 1 reported to the Administrator and staff that a Certified Nursing Assistant (CNA 1) used profanity (obscene language) and was rough while transferring Patient 1 from a wheelchair to bed. On 4/17/18, an unannounced visit was conducted at the facility to investigate reported FRI. The facility failed to follow their policy “Abuse Prevention, Intervention, Investigation and Crime Reporting" to ensure Patient 1 was free of physical and verbal abuse from CNA1, who cursed and threw Patient 1's legs onto the bed against the patient's will. As a result, Patient 1 felt hurt, emotionally distressed, and complained of pain to the neck, lower back, and left ankle. During a review of Patient 1's Admission Record (AR), the AR indicated Patient 1, was a 67-year-old male, who was admitted to the facility on 6/3/2017 and last readmitted on 1/23/2018 with diagnosis including severe obesity (being overweight; an abnormal or excessive fat accumulation that presents a risk to health), generalized muscle weakness, and difficulty walking. A review of Patient 1's History and Physical report (H/P), dated 1/26/2018, indicated the patient had the capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/30/2018, indicated Patient 1 was able to understand and be understood by others. According to the MDS, Patient 1 required two or more staff physical assist with bed mobility, transferring to and from bed, chair, or a standing position, moving from one location to another, dressing, toilet use and personal hygiene. The MDS indicated Patient 1 used a wheelchair and/or walker for mobility and was occasionally incontinent (inability to control) of bowel and bladder. A review of Patient 1's Nurses Progress Notes (NPN), dated 4/16/2018 and timed at 4:12 p.m., indicated the facility's social services director (SSD) and administrator (ADM) were notified on 4/16/2018 of CNA 1’s inappropriate treatment to Patient 1 on 4/14/2018. A review of the facility's Verification of Incident Investigation and Administrative Summary report, dated 4/20/2018, indicated CNA 1 was transferring Patient 1 from a wheelchair to bed and she had a hard time due to the weight of Patient 1's legs. The report indicated CNA 1 admitted to the use of a profanity. During an interview on 4/17/2018 at 11:56 p.m., the administrator (ADM) stated on 4/14/2018, CNA 1 used profanity toward Patient 1. The ADM stated CNA 1 said she did so because Patient 1 threw a remote control at her face. During an interview on 4/17/2018 at 12 p.m., Patient 1 stated on 4/14/2018, CNA 1 physically and verbally abused him. Patient 1 stated CNA 1 grabbed his legs and swung them on the bed like a ‘sack of grain’. Patient 1 stated he tried to get his legs off the bed, but CNA 1 grabbed his legs and threw them over the side of the bed again. Patient 1 stated it caused a lot of pain to his neck, lower back, and left ankle. Patient 1 stated he felt bad and worthless the way CNA 1 treated him. During an interview on 4/17/2018 at 1:10 p.m., Patient 1's roommate (Patient 2), who was alert with intact memory stated on 4/14/2018, he heard a squabble (a noisy quarrel about something petty or trivial) between Patient 1 and CNA 1. Patient 2 stated Patient 1 was screaming for help. During an interview on 6/15/2018 at 9:20 a.m., CNA 1 stated Patient 1 was about to fall on 4/14/2018, therefore, she grabbed the patient's legs and placed them on the bed. CNA 1 stated while caring for Patient 1 she said, "F--- y--" to the patient because Patient 1 threw a remote control at her face. According to CNA 1, she should not have cursed at Patient 1, but it was a natural reaction. A review of the facility's policy and procedure titled, "Abuse Prevention, Intervention, Investigation and Crime Reporting" with a revised date of 11/2016, indicated patients had the right to be free from abuse. It also indicated the facility had to assure patients safety by prohibiting verbal, mental, physical abuse, and corporal punishment. It also indicated the facility would ensure there was no use of derogatory language, rough handling or inattention to patients while providing care. The facility failed to follow their policy “Abuse Prevention, Intervention, Investigation and Crime Reporting" to ensure Patient 1 was free of physical and verbal abuse from CNA 1, who cursed and threw Patient 1's leg onto the bed against the patient's will. As a result, Patient 1 felt hurt, emotionally distressed, and complained of pain to the neck, lower back, and left ankle. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.