Other·June 6, 2023

42 CFR §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 22 CCR §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. 22 CCR §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. On 5/10/2023, the California Department of Public Health made an unannounced visit to the facility to investigate an incident related to abuse and quality of care. The facility failed to protect the resident’s right to be free from verbal abuse, when Licensed Vocational Nurse 1 (LVN 1) yelled and spoke loudly to Resident 1. As a result, on 4/30/2023, Resident 1 suffered emotional distress which affected her psychosocial well-being resulting in Resident 1 losing sleep, crying, feeling fearful, unsafe, and feeling like a child. A review of the admission record indicated Resident 1 was admitted to the facility on 12/3/2021, with diagnoses including dysphagia (difficulty or discomfort swallowing) following cerebral infarction (damage to the brain due to a loss of oxygen to the area), and a gastrostomy (a tube inserted through the wall of the abdomen to the stomach, which may be used for feeding). A review of the physician`s history and physical dated 10/19/2022, indicated Resident 1 had the capacity to make decisions. A review of Resident 1's most recent quarterly Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/9/2023, indicated Resident 1 had intact cognition evidenced by consistent and reasonable decisions. The MDS further indicated Resident 1 was totally dependent on staff for toilet use, and eating, and required extensive assistance with one-person physical assistance for dressing, bed mobility, and personal hygiene. A review of the staff assignment sheet dated 4/29/2023 for 11 PM to 7 AM shift, indicated LVN 1 was assigned to Resident 1. During an interview on 5/10/2023 at 10:24 AM, Resident 1 stated LVN 1 yelled at her not only once but multiple times. Resident 1 stated, "On 4/30/2023 at around 2 AM when LVN 1 yelled at me, I told him don't yell at me, I am not your child." Resident 1 stated, "LVN 1 talks loudly all the time, but he yelled at me on 4/30/2023. He told me I don't like you and I told him I am going to report you." Resident 1 was observed crying. Resident 1 stated, "That night I told Registered Nurse Supervisor 1 (RN 1) that LVN 1 yelled at me, and I do not want him to come back. Why would I want a person who does not like me to take care of me. I did not want the registry (a list of nurses who are legally licensed and trained to practice nursing) CNAs to come back either." Resident 1 further stated, "Next day I told LVN 2 about the incident.” Resident 1 was observed crying again. Resident 1 stated, "I even told my family about the way LVN 1 treated me. From day one of my stay in the facility, LVN 1 did not like me. When he was assigned to me at nights, I did not sleep. I had to stay awake and watch everything that he was doing." Resident 1 stated, "I was scared to tell the staff that I do not want LVN 1 to take care of me." Resident 1 stated she was alright now. She stated she had better sleep at night knowing LVN 1 was no longer taking care of her." A review of the facility's written Investigation Report dated 5/4/2023, indicated Resident 1 reported to LVN 2 regarding the alleged verbal abuse towards her by LVN 1 on 4/30/2023 at 9:45 PM. Resident 1 reported that, "On 4/30/2023 around 2:30 AM, two Certified Nursing Assistants (CNA) from the registry were cleaning me. The CNA that was helping my nurse took the pillow from underneath my left arm. I asked my CNA to return my pillow, but she said I did not have a pillow there for her to return. Then, the CNA left and came back with LVN 1. LVN 1 started yelling at me and saying, I listened to the way you treat my CNAs.” The investigation report further indicated that Resident 1`s roommate verified the incident Resident 1 reported, did occur and LVN 1 did in fact yell at her. The facility`s investigation report indicated several residents stated LVN 1 raises his voice, yells at other residents, and gets agitated easily. The facility`s conclusion of the allegation of verbal abuse by LVN 1 indicated that the verbal abuse did occur, and the facility will not tolerate any type of verbal abuse towards their residents. On 5/4/2023, LVN 1 was terminated. During an interview on 5/10/2023 at 9:40 AM, The Administrator (ADM) stated the alleged abuse incident happened on 4/30/2023 at around 2:30 AM. The ADM stated that Resident 1 was being changed by two registry CNAs and she requested her left arm pillow to be returned underneath her arm. One of the CNAs stated there was no pillow originally and Resident 1 insisted there was. Thereafter, CNA left the room and came back with LVN 1. The ADM stated based on Resident 1`s report, LVN 1 yelled at her and treated her like a child. The ADM sated LVN 1 generally speaks with a loud voice. The ADM further stated there were other incidents that facility staff members had issues with LVN 1`s speaking loudly. The ADM stated LVN 1 talked loudly and in a commanding way, and the Director of Nursing (DON) had previous conversations regarding this matter with him. The ADM stated on 4/30/2023 at around 9:45 PM, Resident 1 reported to LVN 2 that LVN 1 yelled at her. The ADM stated LVN 2 called me that night. The ADM stated, "I came to the facility on 5/1/2023 around 6 AM and that was when I had a conversation with LVN 1, and I told him that I need to start an investigation regarding this incident, and I suspended him for three days." During an interview on 5/10/2023 at 12:04 PM, LVN 2 stated Resident 1 was very alert, and had slurred speech (not being able to pronounce each word clearly). LVN 2 stated, "I worked on Sunday 4/30/2023 during the 3PM-11PM shift and I was assigned to Resident 1. At around 9:45 PM, Resident 1 stated that the night before she was having a disagreement about a pillow with the CNAs. She also told me that LVN 1 yelled at her because of the disagreement with the CNAs.” LVN 2 stated, "LVN 1 is a big guy, normally he has a big tone, he could get loud.” LVN 2 stated Resident 1 was crying when disclosing the incident. LVN 2 stated, "I reported the alleged verbal abuse incident to the Administrator that night around 10 PM." LVN 2 stated Resident 1 was emotionally affected because of LVN 1 yelling at her. During an interview on 5/10/2023 at 12:48 PM, the DON stated, LVN 1 was tall, and his voice was husky and loud, and some residents get intimidated because of his voice. The DON stated there were some residents who did not like LVN 1 because of his voice. The DON stated, "The ADM and I talked to LVN 1 about his voice. We told him he needs to lower his voice. Being nurses, we must really adjust ourselves, we cannot say this is my voice." The DON stated LVN 1 received previous in-services regarding customer service, and elder abuse. During an interview on 5/10/2023 at 1:10 PM, the Director of Staff Development (DSD) stated LVN 1 was terminated. The DSD stated, "Sometimes some people think LVN 1 was mad or angry but that was the way he talks. The DSD stated, "The management decided to let LVN 1 go, because residents complain that LVN 1 treats them like a child." On 5/11/2023 at 11:17 AM, during an interview, Family Member 1 stated Resident 1 reported to her that LVN 1 was not attending to her needs. Family Member 1 stated Resident 1 was unhappy with the way LVN 1 talked to her. Family Member 1 stated Resident 1 reported to her that LVN 1 raised his voice at her, and she felt uncomfortable. Family Member 1 stated, "Resident 1 was very emotional and very tearful with me when she told me about the incident that happened on 4/30/2023. She could barely get the words out of her mouth because every time she was trying to explain, she got more and more distraught." Family Member 1 stated Resident 1 did complain about not being able to sleep occasionally when LVN 1 was taking care of her. Family Member 1 stated whenever LVN 1 would scream at her or he would not provide her requested assistance, she was not able to sleep well. Family Member 1 stated, "It is hard for Resident 1 to let it go; it is hard for her to recover from this anxiety that she was going through." Family Member 1 stated part of this was because of Resident 1`s condition, from a total independent person for all her life to a total dependent person. During a telephone interview on 5/12/2023 at 10:48 AM, CNA2 stated, "I remember on 4/30/2023, I was working in the facility during the 11PM-7AM shift. RN 1 switched my assignment and assigned Resident 1 to me because Resident 1 was not happy with her previous CNA. I remember that when I changed Resident 1, I called LVN 1 to assist me to pull her up. I saw Resident 1 turn her face away from LVN 1 when he was at her bedside. I asked her why you turned your head, she said LVN 1 doesn't like me." During a telephone interview on 5/12/2023 at 11 AM, CNA 4 stated she worked in the facility on 4/29/2023 during the 11PM-7AM shift, and she was assigned to Resident 1. CNA4 stated, "At around 2 AM, when we were changing Resident 1, Resident 1 asked me to put the pillow back under her left arm. I told her that there was no pillow there, but I can get her one. Resident 1 was not satisfied with the way we placed the pillow under her left arm. I tried different ways to assist her, but she was not satisfied. We decided to ask LVN 1 to help us understand Resident 1." CNA4 stated LVN 1 came to Resident 1`s room and spoke to her in a strict manor, his voice was high tone, commanding and demanding, as if he was talking to a child. LVN 1 told Resident 1 "I do not like the way you treat my CNAs.” CNA4 stated a charge nurse should never talk to any resident the way LVN 1 talked to Resident 1. CNA4 further stated she did not like the way LVN 1 spoke to Resident 1. CNA4 stated LVN 1 instructed me to leave the room. CNA4 stated, "When I returned to the room, Resident 1 was not talking anymore. She was emotionally affected by the way LVN 1 talked to her. She just told me that she does not want LVN 1 to come back to her room." During an interview on 5/12/2023 at 12 PM, the ADM stated LVN 1 quit on his own. The ADM stated on 5/4/2023, when LVN 1 came to the facility, we were going to discuss the incident with him, but he immediately stated, "I do not want to talk about this, I already have a job and I just need to go, I have to go." LVN 1 had a loud commanding voice. LVN 1 talking to Resident 1 in a loud commanding voice was not right. We do not talk to the residents like that. My plan was to talk to LVN 1 and address this issue." The ADM stated, "I do not know what the definition for verbal abuse is, but I just want good customer service for our residents, and I was not happy with the way LVN 1 spoke to Resident 1." The ADM stated, "I did not know that other residents also had issues with the way LVN 1 talked to them until we investigated Resident 1`s complaint." A review of the facility's Elder Abuse In-service Records indicated LVN 1 received Elder Abuse training on 2/7/2023. A review of LVN 1`s Annual Employee Performance dated 2/9/2023, conducted by the facility`s DON indicated LVN 1 was advised to speak calmly, respect the residents, and lower the tone of his voice to improve his performance. A review of the facility`s policy and procedures titled, "Abuse Prevention Program," revised August 2006, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property, and involuntary seclusion. Our facility is committed to protecting our residents from abuse by anyone, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, or any other individuals. Our abuse prevention program provides policies and procedures that govern, as a minimum mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting abuse, stress management, dealing with violent behavior or catastrophic reaction. The facility failed to protect the resident’s right to be free from verbal abuse, when LVN 1 yelled and spoke loudly to Resident 1. As a result, on 4/30/2023, Resident 1 suffered emotional distress which affected her psychosocial well-being resulting in Resident 1 losing sleep, crying, feeling fearful, unsafe, and feeling like a child. The above violation had a direct or immediate relationship to the health, safety, and security of Resident 1.