Health inspection·November 13, 2024

T22 §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. 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 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. On 10/16/24 at 10:43 AM, an unannounced visit was made to the facility to investigate a Facility Reported Incident (FRI) regarding an incident of alleged resident abuse. The facility failed to ensure that Patient 1 was free from abuse, in accordance with the facility’s policy and procedure(P&P) titled “Management of Dangerous Behavior,” and “Abuse, Neglect, Exploitation, and Misappropriation Prevention Program,” in responding to manage Patient 1’s aggressive behavior when: 1. Program Counselor (PC) 10 grabbed Patient 1 from behind and took down Patient 1 to the ground on 10/12/2024 between 8:55 am to 9 AM, due to a Patient-to-Patient altercation between Patients 1 and 2. 2. Patient 1 and PC 10, staff to patient altercation was not reported to facility Program Manager Counselor (PMC) 2 until 10/12/24 at approximately 4:57PM (7 hours later) 3. Patient 1 and Patient 2’s altercation was not immediately reported to facility PMC 2 until 10/12/24 at approximately 4:57PM (7 hours later) These deficient practices placed Patient 1 at risk of further abuse and cause psychosocial (covers a person's mental, emotional, social, and spiritual health) distress, physical injuries, hospitalization, and death. Findings: A review of Patient 1’s Admission Record indicated a 32 year old male patient was admitted to the facility on 2/16/2023, with diagnoses that included mood affective disorder (marked disruptions in emotions (severe lows called depression or highs called hypomania or mania), autistic disorder (harder for them to communicate and socialize with others), and mild intellectual disabilities (conditions that affect functioning in two areas: Cognitive functioning, such as learning, problem solving and judgement). A review of Minimum Data Set (MDS - a federally mandated patient assessment tool), dated 8/26/2024, indicated Patient 1’s cognitive skills (ability to make daily decisions) was moderately impaired. The MDS indicated Patient 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as patient completes activity) with eating and personal hygiene, and independent with toileting, dressing and walking. A review of Patient 2’s Admission Record indicated a 46 year old male patient was originally admitted to the facility on 12/20/2019 and readmitted on 3/3/2023 with diagnoses that included, bipolar disorder (a brain disorder that causes extreme highs and lows in your moods), schizophrenia (a serious mental illness that affects a person's ability to think, feel, and behave normally), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Minimum Data Set (MDS - a federally mandated patient assessment tool), date 9/13/2024, indicated Patient 2’s cognitive skills (ability to make daily decisions) was moderately impaired. The MDS indicated Patient 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as patient completes activity) with eating and personal hygiene, and independent with toileting, dressing and walking. A review of Patient 1’s facility document titled “Progress Notes,” dated 10/12/2024, timed at 9:32 AM, indicated at 8:55 AM, Patient 1 became upset and aggressive during a group activity, after Patient 2 “flipped” him. The Progress Note indicated no physical contact was made and Patient 1 was counseled. The Note did not indicate immediate notification to the facility administer/designee or interventions conducted regarding the abuse incident until 10/13/2024. A review of Patient 1’s facility document titled “Progress Notes” dated 10/13/2024 at 12:16 AM, the Progress Note indicated, on 10/12/24 at approximately 4:57 PM, Patient 1 approached PMC 2 and the RN supervisor and reported the incident (regarding PC10) to an unnamed staff during the morning shift. The Note indicated PC 10 asked Patient 1 about the incident that occurred earlier the same day (10/12/24) at around 8:55 AM between Patient 1 and Patient 2. The Progress Note indicated Patient 1 and PC10 were in the office and PC 10 grabbed Patient 1 by the neck. The document further indicated after leaving the office, Patient 1 saw Patient 2 and became agitated and quickly punched Patient 2 on the face and to the back of the head. The Progress Note also indicated, Patient 1 felt PC 10 grabbed him from behind, picked him up and slammed him onto the floor. During a concurrent observation and interview on 10/16/2024 at 11:30 AM with Patient 1 in the hallway next to the Dining Room, Patient 1 was observed pacing (to walk with regular steps in one direction and then back again) back and forth. Patient 1 was observed with a 1:1 sitter (staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act), Certified Nurse Assistant (CNA) 2. Patient 1 stated, he remembered reporting an abuse incident to an unnamed staff and stated, Patient 2 was teasing him, so he hit Patient 2 (unable to recall where). Patient 1 stated the incident between Patient 1 and Patient 2 occurred on Saturday (10/12/2024) sometime in the morning. Patient 1 stated, PC 10 spoke to Patient 1 in the office and when Patient 1 left the office and Patient 1, saw Patient 2, who gave him a “finger sign” so he hit him on the face. Patient 1 stated, PC 10 grabbed him from behind and slammed Patient 1 onto the Dining Room floor. During an interview on 10/16/2024 at 11:45 AM with Patient 2, in the hallway next to the Dining Room, Patient 2 stated, on 10/12/24, Patient 1 hit Patient 2 on the face. Patient 2 stated he could not remember why Patient 1 hit him. During an interview on 10/16/2024 at 11:55AM, with PC 5, PC 5 stated, she worked on 10/12/2024. PC 5 stated, the incident with Patient 1 and PC 10 occurred around 9 AM when Patient 1 and Patient 2 had an altercation at the courtyard. PC 10 took Patient 1 to the office to be counseled. PC 5 stated, a few minutes after the incident, PC 5 heard a Code Yellow (code called for everyone to come and intervene to prevent dangerous behavior) in the Dining Room. PC 5 stated, when she came, she saw PC 10 holding Patient 1 from behind, then Patient 1 hit Patient 2 and tried to go after Patient 2. PC 5 stated that was the time when PC 10 put Patient 1 to the ground by himself. PC 5 stated, the incident was not reported to the administrator/designee, as per the facility policy, any type of abuse should be reported to the facility administrator/designee within 2 hours. During an interview on 10/16/2024 at 1:30 PM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, he was the charge nurse in the afternoon shift on 10/12/2024. LVN 3 stated, the abuse incident between Patient 1 and 2, and PC 10 was not reported immediately to the Administrator/ designee. LVN 3 stated Patient 1 reported the alleged abuse to Program Counselor [PMC] 2 “just before 5 PM,” that day [10/12/24], even though the alleged abuse occurred around 9 AM. LVN 3 could not state why the incident of Patient 1 and Patient 2 abuse, and Patient 1 and PC 10 abuse was not reported right away to the Administrator/Designee. LVN 3 stated that any type of abuse should be reported within 2 hours according to the facility’s P&P. During an interview on 10/16/2024 at 2:45 PM, with CNA 3, CNA 3 stated she was sitting next to Patient 2 on the day of the incident on 10/12/24. CNA 3 stated, she witnessed Patient 1 hit Patient 2 on the face, then saw PC 10 grab Patient 1 and put him to the ground and held Patient 1 down on the floor. CNA 3 stated, she did not report the incident, because she thought someone else would report the alleged abuse. During an interview on 10/16/2024 at 2:55 PM with the Administrator (ADM), the ADM stated, what PC 10 did to Patient 1 was considered abuse, since PC 10 grabbed Patient 1 and dropped the patient to the ground. The ADM stated restraining an aggressive resident is not the facility’s policy. The ADM stated, the facility’s P&P required at least 2 people to contain an aggressive patient to prevent injury to the resident. The ADM stated, following the facility’s P&P was to ensure the safety of the patients and staff. The ADM stated, the incident was not reported timely, and the altercation between Patient 1 and 2 was not reported timely as well. The ADM stated, both incidents occurred around 9 AM and was not reported to PMC 2 until 4:57 PM on 10/12/24. The ADM stated, the facility did not have any documentation of the incidents prior to the report at 4:57 PM. During an interview on 10/16/2024 at 3:35 PM with PMC 2, PMC 2 stated, that the facility's P&P for managing an aggressive patient would be to have at least 2 people to go between the resident/s and build a human wall. Facility staff should not grab a patient from behind and throw the patient to the ground. The PMC 2 stated it was considered abuse. PMC 2 stated the facility’s P&P should be followed to prevent injury to the patient and staff. During an interview on 10/17/2024 at 8:05 AM with Program Director (PD) 1, PD 1 stated program directors oversee program managers, program counselors, and mental health workers. PD 1 stated, that according to the facility’s P&P, there needs to be at least 2 people to be present when managing an aggressive resident, to deescalate the situation. PD 1 stated staff should counsel or create a human barrier between patients who are having an altercation. PD 1 stated, there was no reason for a program counselor to grab a patient and take the patient down since that would be considered abuse. During an interview on 10/17/2024 at 2:10 PM with the ADM, ADM stated PC 10 did not follow the facility’s P&P on “Abuse” and “Management of Dangerous Behavior,” when PC 10 threw Patient 1 to the ground on 10/12/2024. The ADM stated the altercation between Patient 1 and 2 that happened at the same time should have been reported immediately as well. The ADM stated both incidents could have caused injury and reoccurrence of abuse. A review of the facility’s policy and procedure (P&P) titled “Management of Dangerous Behavior,” dated 10/1/2024, indicated; a) the goal of all interventions is to prevent further escalation and ensure a safe environment for the Patient involved and other Patient s, b) the use of systematic and planned intervention strategies minimizes the risk of injury to both Patient s and staff, c) restraints has the potential to produce serious consequences both physically and psychologically, and therefore should be only used physically and psychologically, therefore should only be used only when necessary, d) “Physical restraint” means use of manual hold to restrict freedom of movement of all part of a person’s body for purpose of behavioral restraint, it may involve stabilizing a Patient against the wall, on the floor or where they stand, and restrain only as a team, single person restraints should be avoided, problems with one on one restraints includes inflicting injury by misjudging to hold safely. A review of the facility’s policy and procedure (P&P) titled “Abuse, Neglect, Exploitation, and Misappropriation Prevention Program” revised 4/2021, indicated; a) Patients have the right to be free from abuse or neglect, this include but not limited to physical abuse, b) protect Patients from abuse by anyone including but necessarily limited to facility staff and other Patients . A review of the facility’s policy and procedure (P&P) titled “Abuse, Neglect, Exploitation, or Misappropriation – Reporting and Investigating” revised 9/2022,indicated: a) All reports of Patient abuse, neglect are reported to local, state and local agencies (as required by current regulations) and thoroughly investigated by facility management, b) If Patient abuse, neglect is suspected, the suspicion must be reported immediately to the administrator and to other officials according to the state law, c) the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies which includes; the state and licensing/ certification agency, the local/state ombudsman, and law enforcement officials, and d) “immediately” is defined as within two hours of an allegation involving abuse or result in serious bodily injury. The facility failed to ensure that Patient 1 was free from abuse, in accordance with the facility’s policy and procedure(P&P) titled “Management of Dangerous Behavior,” and “Abuse, Neglect, Exploitation, and Misappropriation Prevention Program,” in responding to manage Patient 1’s aggressive behavior when: 1. Program Counselor (PC) 10 grabbed Patient 1 from behind and took down Patient 1 to the ground on 10/12/2024 between 8:55 am to 9 AM, due to a Patient-to-Patient altercation between Patients 1 and 2. 2. Patient 1 and PC 10, staff to patient altercation was not reported to facility Program Manager Counselor (PMC) 2 until 10/12/24 at approximately 4:57PM (7 hours later) 3. Patient 1 and Patient 2’s altercation was not reported to facility PMC 2 until 10/12/24 at approximately 4:57PM (7 hours later) These deficient practices placed Patient 1 at risk of further abuse and cause psychosocial (covers a person's mental, emotional, social, and spiritual health) distress, physical injuries, hospitalization, and death. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients.