Other·May 9, 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; 22 CCR §72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (c) Each facility shall establish at least the following: (1) Personnel policies and procedures which shall include: (A) Written job descriptions detailing qualifications, duties and limitations of each classification of employee available to all personnel. (B) Employee orientation to facility, job, patient population, policies, procedures and staff. (C) Staff Development. 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 3/27/2024, an unannounced visit was made to the facility to conduct the facility reported incident regarding abuse. The facility failed to provide protection from sexual abuse (non-consensual sexual contact of any type with a resident, including sexual harassment, sexual coercion, or sexual assault) by facility staff, for Resident 1. Resident 1 alleged sexual abuse by Certified Nurse Assistant (CNA) 1, when CNA 1 touched the resident’s private parts and held Resident 1’s hand on his (the CNA’s) private part. As a result, on 3/23/2024, Resident 1, an 82-year-old female, had psychological distress (a state of emotional suffering), was crying, and reported feeling afraid, ashamed, anxious and guilty. A review of Resident 1’s Admission Record indicated the facility admitted the resident on 3/15/2024 with the diagnoses including the lack of coordination (impaired balance) and abnormalities of gait (walking pattern) and mobility. A review of Resident 1’s History and Physical dated 3/18/2024, indicated the resident was transferred to the facility for physical therapy (care that helps people with physical and functional limitations caused by injury or disease) after suffering a fall on 3/12/2024. The History and Physical indicated Resident 1 did have medical decision-making capacity. A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 3/20/2024, indicated the resident was cognitively intact (able to think, understand, and reason). A review of the facility’s Nurse Staffing Assignment dated 3/23/2024, indicated CNA 1 was assigned to take care of Resident 1 during the 7 AM to 3 PM shift. According to a review of the Situation, Background, Assessment, and Recommendation (SBAR, a structured communication framework that can help teams share information about the condition of a patient) Communication Form and Progress Note dated 3/25/2024 at 2 PM, the resident was not feeling good and felt weird. The note indicated Resident 1 called Caregiver (CG) 1 around 2 PM on 3/23/2024 and informed CG 1 the assigned CNA touched Resident 1’s private parts and held the resident’s hand on his (the CNA’s) private part. The note indicated Resident 1’s family and physician were notified. A review of Resident 1’s Social Services Note dated 3/25/2024 at 5:40 PM, indicated staff were informed Resident 1 wanted to report something that happened on 3/23/2024. The note indicated Resident 1 stated that her CNA improperly touched her private area. The note indicated CNA 1 was no longer at the facility and a psychologist (a mental health professional who uses psychological evaluations and talk therapy to help people learn to better cope with life and relationship issues and mental health conditions) consultation (a meeting with an expert or professional, such as a medical doctor, to seek advice) was scheduled for 5 PM that day. The note indicated Resident 1’s emotions and behavior would be continuously monitored for any changes, and indicated support would be provided as needed. A review of Resident 1’s Psychotherapy Note dated 3/25/2024, indicated the therapist inquired about the resident’s recent sexual abuse allegation. The note indicated the therapist addressed Resident 1’s feelings of guilt and shame. The note indicated Resident 1 initially presented as generally calm with a congruent affect (when a mood matches a person’s behavior) but later became tearful at various points during the session. The note indicated Resident 1 reported sleep disturbance due to frequent urination and distressing dreams. The note indicated Resident 1 was able to revisit the event, fully described related details, and processed associated thoughts and feelings that included guilt, shame, humiliation, anxiety, fear, confusion, butterflies in the stomach, some anxiousness due to intrusive thoughts since the event, and fear of CNA 1. During an interview on 3/27/2024 at 8:53 AM, Resident 1 stated the incident happened on Saturday 3/23/2024 around 1 PM to 2 PM. Resident 1 stated she had to have her incontinent brief changed and called her CNA who was male. Resident 1 stated CNA 1 told her to lie back down and then started to touch her vagina and move his hand in circles. Resident 1 stated she was frightened. Resident 1 stated CNA 1 then took her hand and put it over his private area, and she felt CNA 1’s private area getting bigger. Resident 1 stated she tried to move her hand, but CNA 1 grabbed it and placed it back on his private area. Resident 1 stated she said 'no' three times. Resident 1 stated afterwards CNA 1 started massaging her shoulders. Resident 1 stated she was scared because the CNA ' s usually just change her incontinent brief and leave; but this CNA stayed a while. Resident 1 stated she did not know who to talk to and remembered she had a previous caregiver at home. Resident 1 stated she called the caregiver and told them what happened. Resident 1 stated the caregiver came to the facility on Monday 3/25/2024. Resident 1 stated she did not remember the CNA’s name, but indicated the CNA was tall, wearing black scrubs, and had a little darker skin. Resident 1 stated she saw CNA 1 again on Monday, which made her scared. Resident 1 was observed crying and tearful. Resident 1 stated she was afraid and indicated she was worried she would get moved from the facility and not get taken to activities, because she told someone what happened. During an interview on 3/27/2024 at 11:50 AM, the Social Services Director (SSD) stated she heard of what happened on 3/25/2024 at 2 PM, that Resident 1 was crying, and was afraid and ashamed that she could not talk about the incident the day it happened. The SSD stated Resident 1’s caregiver from home encouraged her to tell the facility about what happened. The SSD stated she along with the Administrator, Director of Staff Development (DSD), and Activities gathered in Resident 1’s room. The SSD stated Resident 1 indicated the incident happened on Saturday 3/23/2024 during the 7 AM to 3 PM shift. The SSD stated Resident 1 could not remember the exact time but remembered the CNA was on the morning shift, because he left after 3 PM. The SSD stated Resident 1 indicated CNA 1 came to the resident’s room to change her incontinent brief; and once he opened the incontinent brief the CNA put his finger on the resident’s private area. The CNA then took the resident’s hand and put it on his private area. The CNA stated Resident 1 indicated she said 'no' three times, but he kept rubbing the resident’s private area. The SSD stated Resident 1 was crying and was afraid her son might get upset if he found out. The SSD stated Resident 1 stated she never had any similar experiences in the past. The SSD stated Resident 1 felt ashamed. During an observation on 3/27/2024 at 1:09 PM, the facility’s surveillance video was viewed. The video revealed on 3/23/2024 at 2:05 PM, CNA 1 entered Resident 1’s room and put on gloves. At 2:06 PM CNA 1 was observed pulling the curtain around Resident 1’s bed. At 2:07 PM, CNA 1 was observed coming out from behind the curtain of Resident 1’s bed and exiting the resident’s room. At 2:16 PM, CNA 1 was observed re-entering Resident 1 room. At 2:19 PM, CNA 1 was observed pulling the curtain around Resident 1’s bed. At 2:20 PM CNA 1 was observed coming out from behind the curtain of Resident 1’s bed not wearing gloves. At 2:25 PM CNA 1 was observed entering Resident 1’s bathroom by himself, was observed in the bathroom for a few minutes, and then observed leaving Resident 1 ' s room. On 3/27/2024 at 3:30 PM, during a telephone interview, CNA 1 stated he did not touch Resident 1’s vagina. CNA 1 stated he did not make Resident 1 touch his private area. CNA 1 stated he was only doing his job to clean Resident 1 and that his registry agency did not provide him with abuse training. CNA 1 stated the facility did not provide him with abuse training during his orientation. CNA 1 stated sometimes the facility would give information on abuse prevention and reporting but could not specify when his last abuse training was. During a telephone interview on 3/28/2024 at 11:39 AM, CG 1 stated she knew Resident 1 for over two years and knew the resident before she was transferred to the facility. CG 1 stated Resident 1 called her on Saturday 3/23/2024 and informed her that a CNA touched the resident’s private area when he was changing the resident’s incontinent brief. CG 1 further stated Resident 1 informed her the CNA also made the resident touch his private area. CG 1 stated she went to the facility on Monday 3/25/2024 and Resident 1 got sacred when she saw CNA 1. CG 1 stated Resident 1 felt very uncomfortable and that was when she informed the facility staff about what had happened between Resident 1 and CNA 1. During an interview on 3/28/2024 at 12:02 PM, the DSD stated CNA 1 was from the registry and after the allegation, CNA 1 was asked to leave the facility. The DSD stated CNA 1 would not be returning to the facility. The DSD confirmed CNA 1 did not have an employee file, nor did CNA 1 attend any of the abuse in-services dated 2/3/2023, 4/15/2023, 5/2/2023, 11/15/2023, and 3/1/2024. On 3/28/2024 at 2:25 PM, during an interview and concurrent record review, the DSD stated registry staff were not provided with formal abuse training when they come to the facility because they were not employees on the facility's payroll. The DSD stated the registry staff were usually provided abuse training by their agency. The DSD stated there was a potential for staff to abuse residents if they were not provided with abuse training. During an interview on 3/28/2024 at 2:58 PM, the Administrator stated Resident 1 explained that CNA 1 came into her room and touched her vagina area. The Administrator stated CNA 1 was asked to make a statement and leave the facility. The Administrator stated CNA 1 would not be allowed back in the facility and that Resident 1 was cognitively intact. The Administrator stated Resident 1’s story never changed when she told it to the facility staff and to the police officers. The Administrator stated he was the abuse coordinator, and that CNA 1 did not attend the facility's abuse in-services, as all staff should be trained on abuse. The Administrator stated there could be a potential for abuse to occur if staff were not provided with abuse training. A review of the facility’s Follow-Up Investigation Report dated 3/29/2024, indicated on Monday 3/25/2024 around 2:15 PM, the Administrator asked the SSD to ensure Resident 1 was safe with frequent visits for the next few days. The report indicated CNA 1 was moved away from Resident 1, was asked to make a statement, and was asked to leave the facility. The report indicated the psychologist came to meet with Resident 1 the same day. The report indicated the police came to the facility at 5:30 PM and took a statement from Resident 1. The report indicated Resident 1 told the police officers and the psychologist the same story. The report indicated the facility could not disregard Resident 1’s allegations and safety concerns because the resident was alert and oriented. The report indicated the facility would continue to provide room visits with Resident 1 to reinforce safety. The report further indicated CNA 1 was no longer allowed in the facility. A review of the Master Staffing Agreement between the facility and Registry Agency 1, dated 10/25/2018, indicated "because the client controls the facility in which personnel will perform work, client shall be responsible for compliance with Occupational Safety and Health Act and comparable state and local occupational safety and health regulations and standards and shall provide Personnel with a workplace free from occupational hazards." A review of the facility’s policy and procedure titled, "Abuse and Neglect Prohibition Policy," reviewed 6/2023, indicated it was the facility ' s policy to prohibit abuse, mistreatment, neglect, involuntary seclusion of all residents. The purpose of the policy was to ensure facility staff were doing all that was within their control to prevent occurrences of abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property for all residents. Abuse was defined as the willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caretaker of services which were necessary to maintain physical or mental health including the following. Sexual abuse was non-consensual sexual contact of any type with a resident, including sexual harassment, sexual coercion, or sexual assault. The facility failed to provide protection from sexual abuse by facility staff, for Resident 1. Resident 1 alleged sexual abuse by CNA 1, when CNA 1 touched the resident’s private parts and held Resident 1’s hand on his (the CNA’s) private part. As a result, on 3/23/2024, Resident 1 had psychological distress, was crying and reported feeling afraid, ashamed, anxious and guilty. The above violations had a direct or immediate relationship to the health, safety, or security of Resident 1.