Other·May 17, 2019

F000 INITIAL COMMENTS

F000 DEFICIENCY) COMPLETE DATE The following reflects the findings of the Department of Public Health during an Abbreviated survey for a Facility Reported Incident (FRI) investigation. FRI number: CA00622729 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 36926 The inspection was limited to the specific FRI investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of FRI number: CA00622729.

F607 SS=D Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: 056113 04/17/2019 ALEXANDRIA CARE CENTER 1515 N Alexandria Ave Los Angeles, CA 90027 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Based on interview and record review, the facility failed to implement its policies and procedures to ensure that all residents were protected from potential physical and psychosocial harm, during a facility investigation of alleged employee abuse for one of three sampled Residents (Resident 1). The facility did not remove Certified Nursing Assistant (CNA 1) from duty after Resident 1 made an allegation of physical abuse about CNA 1. This deficient practice had the potential to subject other residents to physical and psychological harm, pending the facility's investigation. Findings: A review of Resident 1's Face Sheet (admission form) indicated the resident was originally admitted to the facility on 1/30/19, with diagnoses that included, but not limited to: fracture of left femur (thigh bone), muscle weakness and difficulty walking. The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/6/19, indicated Resident 1's cognition (mental capacity to make decisions, ability to remember, learn, and understand) was intact. The resident was assessed to have frequent urinary and bowel incontinence (lack of control over urine and bowel). The MDS indicated the resident required extensive assistance with bed mobility, transfer, dressing, toileting and bathing. A review of the facility's investigation regarding the allegation of physical abuse, dated 2/1/19 at 11:50 a.m., indicated Resident 1 verbalized 056113 04/17/2019 ALEXANDRIA CARE CENTER 1515 N Alexandria Ave Los Angeles, CA 90027 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE that CNA 1 roughly moved the pillow during patient care and also stated that CNA 1 was rough during incontinent care. A review of Resident 1's care plan, dated 2/1/19, indicated that Resident 1 was a risk for distressed/fluctuating mood symptoms related to allegation of abuse while receiving care. During an interview on 2/20/19, at 9:15 a.m., Resident 1 stated, "She was rough, she pulled the pillow so fast and it hurt, I just had surgery you know." Resident 1 was not sure of the CNA's name and asked to continue with the interview at another time. During an interview on 2/20/19 at 9:50 a.m., Licensed Vocational Nurse (LVN 1) stated, he was in the middle of passing medications and he heard Resident 1 say, "You are too rough for me." LVN 1 stated that he was in the doorway of Resident 1's room, so he stepped inside the room to the second bed and saw CNA 1 with her hands up in the air. LVN 1 stated that Resident 1 stated to him that CNA 1 was too rough. LVN 1 stated that he called out to another CNA (CNA 2) and asked her to assist CNA 1 to finish the care for Resident 1. LVN 1 further stated, "We immediately changed assignments." LVN 1 stated that usually, they adjust staff assignments because they have to remove the CNA from that assignment if a resident complains. LVN 1 also stated that he tells them (CNAs) not to step on that side of the hallway anymore. LVN 1 stated that Resident 1 calmed down and did not make any more reports about CNA 1 being too rough with her. During a concurrent record review and interview on 2/20/19, at 11:35 a.m., when asked if there was a suspension letter or a return to work document in CNA 1's file, the 056113 04/17/2019 ALEXANDRIA CARE CENTER 1515 N Alexandria Ave Los Angeles, CA 90027 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE Director of Nursing (DON) stated, "No, she continued to work, but was removed from that station side assignment; she was moved to another side." When asked when was the facility investigation was concluded, the DON stated, "It was concluded after five days on 2/7/19." Then DON presented a copy of a letter that the facility had faxed to Department of Public Health on 2/7/19 and stated the letter indicated that the facility had completed their investigation. DON stated that according to the facility's investigation, Resident 1 had stated that CNA 1 could continue with her care and that she did good incontinence care. During a telephone interview with CNA 2 on 2/20/19 at 12:19 p.m., CNA 2 stated that on 2/1/19, during a.m. care, the charge nurse asked her to come and stand in Resident 1's room while CNA 1 gave Resident 1 a bed bath and the patient [Resident 1]said, "Ouch, you are being too rough with me." During a telephone interview with CNA 1 on 2/20/19 at 4:03 p.m., CNA 1 stated she worked on 2/1/19, and that LVN 1 had told her that Resident 1 was soiled and needed to be changed. CNA 1 stated the resident had hip surgery and do have pain. CNA 1 stated she was just turning Resident 1 and the resident yelled out, "Abuse, abuse." CNA 1 stated she called for LVN 1, who was by the door, who then called out for CNA 2 to watch her (CNA 1) finish up care for Resident 1. When CNA 1 was asked if she remained working at the facility that day, CNA 1 stated, "Yes, I worked the rest of the day, but I didn't have that same assignment; I was at the 2nd station." When asked did the facility tell you to go home or not to return to work, CNA 1 stated, "No, they just told me not to go down that way and not to be on that end of the hallway." When asked did the facility tell you the results of their 056113 04/17/2019 ALEXANDRIA CARE CENTER 1515 N Alexandria Ave Los Angeles, CA 90027 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE investigation, CNA 1 stated, "No mam, I am not aware of what transpired; nobody talked to me." During an interview with the Administrator (Admin) on 2/20/19 at 1:05 p.m., the admin stated that he was not at the facility when this investigation took place. Admin stated he was not aware that CNA 1 continued to work, and stated, "We should have pulled her out." A review of CNA 1's time-in and time-out sheet, provided by the facility, indicated that CNA 1 continued to work on 2/1/19 until 3:32 p.m. and returned to work at the facility from 7 a.m. to 3:30 p.m. on 2/4/19 and 2/5/19. According to the Daily Staffing Sheet, CNA 1 was assigned to to other residents in Unit 1 from 2/4/19 through 2/7/19. During an interview on 2/21/19 at 2:20 p.m., Resident 1 stated, "She pulled the pillow very strong and had to clean me, and she was rough." When asked if she had asked CNA 1 to continue her care and had said that she gave good care, Resident 1 stated, "No! I didn't say that." When asked how did it make her feel when that happened with CNA 1, Resident 1 stated, "It made me feel bad, I wondered is she gonna attack me again; is she my enemy? Wouldn't you be afraid?" During an interview on 2/2/19 at 2:40 p.m., when asked what is supposed to happen when there is an allegation of staff to resident abuse, the Administrator (Admin) stated, "We separate the employee from the resident, take them out of the room; they clock out and leave." When asked if that meant the employee leaves the facility, he stated, "Yes." The Admin also stated that the facility usually discusses the results of the investigation with the resident. When asked if the results of this investigation 056113 04/17/2019 ALEXANDRIA CARE CENTER 1515 N Alexandria Ave Los Angeles, CA 90027 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE were discussed with Resident 1, Admin stated he would have to find out. The Admin stated that they also usually ask the resident if they feel safe. When asked if he had asked Resident 1 if she feels safe, the Admin stated, "Not yet, I haven't had a conversation with the Resident." A review of the facility's policy and procedure, titled, "Abuse Prohibition", revised date 7/1/18, indicated that when an allegation of abuse is made, the employee alleged to have committed the act of abuse will be removed from duty, pending investigation. A review of the facility's policy and procedure, titled, "Resident Rights Title 22 (State of California)", dated 7/24/18, indicated the facility will comply with resident rights under Federal law and California Title 22 and will ensure that these rights are not violated. The policy indicated the purpose of the policy was to protect and promote the rights of residents, which included to be free from mental and physical abuse.