Health inspection·August 22, 2024

§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 §72523(a) 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 7/12/2024 the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating a resident's (Resident 1) Family Member (FM) reported that Resident 1 was verbally abused by a Certified Nursing Assistant (CNA 1) by saying inappropriate words. On 7/12/2024, the CDPH conducted an unannounced visit to the facility to investigate the FRI. Upon investigation CDPH determined CNA 1 spoke to Resident 1 using a curse word in a loud, angry, and aggressive tone, in a foreign language that Resident 1 happed to understand. The facility failed to: 1. Ensure Resident 1 was not verbally abused by CNA 1, during Resident 1's physical therapy ([PT] a branch of rehabilitative health that uses exercise and equipment to help patients improve their physical abilities) exercise when CNA 1 said to Resident 1 "let's go man," followed by an expletive (an oath or swear word) in in a language different from commonly spoken English. 2. Ensure the facility staff adhered to the facility's policy and procedure (P/P), titled, "Abuse, suspected abuse, reporting," that indicated residents of the facility have the right to be free from verbal abuse. The facility must protect the residents from abuse by anyone including facility staff. As a result of these deficient practices, Resident 1's feelings were hurt, because Resident 1 made an effort to follow the rehabilitation (a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions) instructions, and CNA 1 did not have to curse at him. This deficient practice had the potential for other episodes of verbal abuse to happen. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1, a 54 year old male, was admitted to the facility on 6/13/2024 with a diagnosis of lobar pneumonia (damaged lung caused by an infection), and pulmonary embolism (a clot in lungs). A review of Resident 3's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 6/20/2024 indicated Resident 1 was able to make independent decisions that were reasonable and consistent and he had the ability to make himself understood and be understood by others. A review of Resident 1's Physician's Order dated on 6/14/2024, indicated Resident 1 was to receive occupational therapy([OT] a branch of health care that helps people who have physical, sensory or cognitive [thoughts] problem) to include therapeutic exercises, therapeutic activity, and activities of daily living ([ADL] task such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating) training three times per week, every day shift, for four weeks. A review of Resident 1's Physician's Order dated 6/14/2024, indicated Resident 1 was to receive PT to include neuromuscular reeducation ([NMRE] prescribed motions to re-develop normal motion within an injured body part), therapeutic activities and gait (how a person walks) training five times per week, every day shift for five weeks. A review of the facility's Summary of Investigative Findings dated 7/4/2024, indicated Resident 1 was in the facility's PT gym with Physical Therapy Assistant 1 ([PTA 1] a licensed clinician who works with patients to help them improve their movement and regain independence) attempting to stand up from his wheelchair to use the parallel bars (a pair of bars that provide two-sided support, helping people maintain their balance during ambulation and coordination exercises). The Summary of Investigative Findings indicated Resident 1 expressed fear of falling and was concerned whether the small woman, who were assisting him, would be able to catch him if he fell during PT. The Summary of Investigative Findings indicated PTA 1 attempted to get Resident 1 to stand but Resident 1 was not interested. The Summary of Investigative Findings indicated CNA 1 who was outside of the PT room was invited inside the PT room by PTA 1 to help accommodate Resident 1. The Summary of Investigative Findings indicated Resident 1 was sitting in his wheelchair as CNA 1 encouraged Resident 1 to stand up saying, "let's go man," followed by an expletive in a language different from commonly spoken English. Resident 1 responded with the same expletive, in English, back to CNA 1, saying "I know what that means" During an interview on 7/12/2024, at 11:49 a.m., Resident 1 stated CNA 1 cursed him out using an expletive in a language different from commonly spoken English. Resident 1 stated that language usually does not bother him because knows and works with people who speak this foreign language, and he chooses not to say anything in order to keep the peace, but why did he (CNA 1) talk and act like that? Resident 1 stated his feelings were hurt and he was embarrassed and humiliated in front of people because he (Resident 1) was making an effort to do the rehabilitation exercises. Resident 1 stated, he stopped to catch his breath and CNA 1 said "putang ina mo" to him. Resident 1 stated it means "F*** you" in the language CNA 1 swore at him. During an interview on 7/12/2024 at 11:55 a.m., the Director of Rehabilitation (DOR) stated Resident 1 wanted to take a break while doing parallel bar exercises, when CNA 1 said "f*** you" to Resident 1 in a language different from commonly spoken English, in response to Resident 1 taking a break. The DOR stated she was caught off guard and shocked and did not know why CNA 1 used that word towards Resident 1. During an interview on 7/12/2024 at 12 p.m., PTA 1 stated she was present (6/28/2024) and heard CNA 1 speaking to Resident 1 in a loud, aggressive tone and stated CNA 1 should not have spoken to Resident 1 that way just because Resident 1 wanted to stop and catch his breath while doing rehabilitation exercises. During an interview on 7/12/2024 at 12:10 p.m., PTA 2 stated she was shocked at what she heard from CNA 1, CNA 1 used an expletive towards Resident 1 during patient care. During an interview on 7/12/2024 at 12:14 p.m., the Director of Staff Development (DSD) stated all residents have the right to be free from any form of abuse including verbal abuse, expletives, and profanities. During an interview on 7/12/2024 at 12:22 p.m., the Director of Nursing (DON) stated residents were here at the facility to recuperate and heal and how they are treated or if they are mistreated could affect them psychologically and physically. During an interview on 7/12/2024 at 1:24 p.m., the Administrator (ADM) stated he learned about the allegation of verbal abuse during an Interdisciplinary ([IDT] a group of healthcare professionals from different fields who work together to provide the best care for a resident) meeting. The ADM stated CNA 1 was unprofessional with poor bedside manners but stated he did not believe what CNA 1 said to Resident 1 qualified as verbal abuse because it was meant to encourage and motivate Resident 1. During a review of the facility's P/P, titled, "Abuse, suspected abuse, reporting," revised 10/2022, the P/P indicated the residents of the facility have the right to be free from verbal abuse. The facility must protect the residents from abuse by anyone including facility staff. The facility failed to: 1. Ensure Resident 1 was not verbally abused by CNA 1, during Resident 1's physical therapy ([PT] a branch of rehabilitative health that uses exercise and equipment to help patients improve their physical abilities) exercise when CNA 1 said to Resident 1 "let's go man," followed by an expletive (an oath or swear word) in in a language different from commonly spoken English. 2. Ensure the facility staff adhered to the facility's policy and procedure (P/P), titled, "Abuse, suspected abuse, reporting," that indicated residents of the facility have the right to be free from verbal abuse. The facility must protect the residents from abuse by anyone including facility staff. As a result of these deficient practices, Resident 1's feelings were hurt, because Resident 1 made an effort to follow the rehabilitation (a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions) instructions, and CNA 1 did not have to curse at him. This deficient practice had the potential for other episodes of verbal abuse to happen. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1