Health inspection·September 24, 2024

§ 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. § 72527. Patients' Rights. (a) 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: (10) To be free from mental and physical abuse. F600 Freedom from Abuse, Neglect, and Exploitation §483.12 Freedom from Abuse, Neglect, and Exploitation The Patient has the right to be free from abuse, neglect, misappropriation of Patient 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 Patient’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; On 8/12/2024 at 12 PM, an unannounced visit was made to the facility to investigate a facility reported incident (FRI) regarding an incident of alleged Patient abuse. The facility failed to protect Patient 1’s right to be free from physical abuse. On 7/30/2024, Certified Nursing Assistant (CNA) 1 reported he witnessed program Counselor (PC) 1 hit the face of Patient 1, who had a diagnosis of unspecified mood disorder (a mental health condition that primarily affects your emotional state.), autistic disorder (neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), and mild intellectual disabilities (slower in all areas of conceptual development and social and daily living skills), after Patient 1 began punching PC 1. This deficient practice resulted in Patient 1 experiencing physical abuse from PC 1. A review of Patient 1’s Admission Record indicated a 32 year old, male patient, admitted to the facility on 2/16/2023 with diagnoses including unspecified mood (affective) disorder, autistic disorder, and mild intellectual disabilities. A review of Patient 1’s Minimum Data Set (MDS, an assessment and screen tool) dated 5/26/2024 indicated Patient 1 had moderately impaired cognition (the ability or mental action or process of acquiring knowledge and understanding). A review PC1’s statement dated 7/30/2024 indicated PC 1 left the dining room area and into the courtyard when Patient 1 was observed with CNA 1 for line-of-sight (LOS - monitoring/supervising the Patient one-on-one) supervision. PC 1’s statement indicated Patient 1 was agitated, pushed PC 1, and began yelling profanities at PC 1. PC 1’s statement indicated Patient 1 postured with a closed fist and attempted to hit PC 1. PC 1’s statement indicated there was no contact and PC 1 tried to defend himself from Patient 1’s attack. A review of CNA 1’s statement dated 7/31/2024 indicated Patient 1 started attacking and punching PC 1. PC 1 then retaliated and punched Patient 1 in the face causing Patient’s nose to bleed. During an interview with Patient 1 on 8/12/2024 at 1:24 PM, Patient 1 stated PC 1 hit his nose. Patient 1 stated he tried to “fist bump” PC 1. Patient 1 stated he pushed PC 1 but could not recall what caused him to push PC 1. Patient 1 stated he had pain on his hand and face and was taken back to his room because his nose was bleeding. Patient 1 stated he feels safe now that PC 1 is not at the facility. Patient 1 stated after PC 1 hit him, “he made me feel bad.” Patient 1 looked upset and could not elaborate what “bad” meant. During an interview with CNA 1 on 8/12/2024 at 3:20 PM, CNA 1 stated while he was covering as Patient 1’s line of sight staff during breaktime on 7/30/2024 around 7:22 pm. During this time Patient 1 started punching PC 1 like "making a fist bump" and PC 1 refused to give Patient 1 a fist bump. CNA 1 stated as he and Patient 1 were walking out of the Dining Room, Patient 1 saw PC 1 and started to attack PC 1 by punching him. CNA 1 stated PC 1 fought back to defend himself and punched Patient 1 in the face which cause the Patient 1’s nose to bleed. CNA 1 stated he tried to stop Patient 1, but everything happened so fast he was not able to stop it. CNA 1 stated PC 1 only punched Patient 1 once. CNA 1 stated that according to facility’s practice, when a staff is providing LOS for a patient, there was no exact distance how close the LOS staff to the patient. CNA 1 stated he was less than three feet away from Patient 1 when the incident between Patient 1 and PC 1 happened. During a concurrent interview and record review of the facility's investigation with the facility's Program Director (PD) on 8/12/2024 at 3:33 PM, PD stated she read the investigation report and” knew something was wrong.” The PD stated when she saw the investigation indicated “self-injury” she knew that there was something going on because the patient would not harm himself, he just scratches himself and he gets scabs, but he would not punch himself in the face. The PD stated she found out PC 1 hit Patient 1 in the face. The PD stated she did not understand the reaction of PC 1, because facility staff were all instructed to walk away during situations were escalated and staff should know when the situation was deescalated. A review of facility’s policy and procedure (P&P) titled “Abuse Prevention Program,” dated 8/2021 indicated Patients have the right to be free from abuse, neglect, misappropriation of Patient property and exploitation. The P&P indicated as part of the Patient abuse prevention, the administration will protect the Patients from abuse by anyone including but not necessarily limited to: facility staff, other Patients, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. The facility failed to protect Patient 1’s right to be free from physical abuse. On 7/30/2024, Certified Nursing Assistant (CNA) 1 reported he witnessed program Counselor (PC) 1 hit the face of Patient 1, who had a diagnosis of unspecified mood disorder (a mental health condition that primarily affects your emotional state.), autistic disorder (neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), and mild intellectual disabilities (slower in all areas of conceptual development and social and daily living skills), after Patient 1 began punching PC 1. This deficient practice resulted in Patient 1 experiencing physical abuse from PC 1. These violations had a direct or immediate relationship to the health, safety, or security of Patient 1.