**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, review of facility grievance reports, review of the State Agency's Long-Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to ensure residents were free from physical, verbal, and mental abuse. This was true for 7 of 13 residents (#3, #5, #6 #10, #11, #12, and #13) reviewed for abuse. This placed Resident #3 in immediate jeopardy of serious harm, impairment, or death when the facility did not protect Resident #3 from abuse by LPN #1. Residents #5, #6, #10, #11, #12, and #13 experienced mental harm when Resident #7 verbally abused them. Findings include: 1. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), neuromuscular dysfunction of the bladder (lack of bladder control due to a brain, spinal cord, or nerve problem), and anxiety disorder. Resident #3's care plan for daily preferences, initiated 5/5/23, stated she preferred female caregivers for personal cares. Resident #3's MAR for May 2023, documented to administer Valium medication to treat anxiety, muscle spasms, and seizures) 10 mg to her vagina at bedtime every Monday, Wednesday, and Saturday for bladder spasms, beginning 5/6/23. Resident #3's MAR, dated 5/13/23, documented LPN #1, (a male nurse) administered the Valium vaginally at bedtime. On 5/23/23 at 9:00 AM, when asked if staff in the facility treated her well and provided good care, Resident #3 stated she liked the facility, and everyone was nice except one nurse. Resident #3 stated LPN #1 was rough and hurt her approximately a week ago when he forcefully inserted a medication into her vagina. She stated LPN #1 pushed so high [into the vagina] it hurt. Resident #3 said she yelled, Ow that hurts! She stated LPN #1 replied, that should not hurt you that much. Resident #3 stated LPN #1 was rude to her and made her feel bad. She said she had vaginal bleeding for 3 days after the medication was inserted and continued to have some vaginal bleeding. Resident #3 stated she filled out a grievance after the incident. She said the SSD talked to her about the grievance and Resident #3 told her what happened. She said the SSD and DON then came and talked to her together and asked her if she would give LPN #1 a second chance to care for her if he apologized. Resident #3 stated she told them she preferred not to have him in her room again. When asked if Resident #3 felt LPN #1 was abusive, she answered quickly in a forceful tone, Yes! The facility's grievance reports were reviewed, dated March 2023, April 2023, and May 2023. There were no grievances related to the incident Resident #3 described. Resident #3's record did not include documentation of the incident she described. There was no documentation in her record of vaginal bleeding. On 5/23/23 at 10:15 AM, LPN #3 was asked if she was aware Resident #3 had bleeding from her vagina after a medication was inserted into her vagina. LPN #3 said she was aware, and the facility was monitoring the bleeding. On 5/23/23 at 10:35 AM, LPN #3 reviewed Resident #3's record and said she could not find documentation of the vaginal bleeding. LPN #1's personnel file, including disciplinary actions, was requested from the facility. The facility provided a type-written document titled, Conversation with [LPN #1] - Summary of Important Facts, dated 5/19/23. The purpose of the document stated, Counseling session in response to formal grievance filed by a resident. The incident review section stated the grievance was regarding an allegation of the insertion of a narcotic pill vaginally, and the patient experiencing significant pain as a result. The grievance report referred to in LPN #1's personnel file was not included with the May 2023 grievances requested by the surveyors. On 5/23/23 at 10:30 AM, the grievance report referenced in LPN #1's personnel file was requested and provided by the Administrator. Resident #3's grievance dated 5/16/23, documented [LPN #1] had to insert a pill vaginaly [sic] he had a bad attitude and argued with me. The report documented [LPN #1] was so rough that I am still bleeding. The resolution on the grievance form stated, SSD and I [DON] talked with resident about [LPN #1], she was satisfied with resolution. [Resident #3] aware she may let IDT know if she requests alternative nurse. The grievance investigation was documented as initiated on 5/18/23, resolved on 5/18/23, and was signed by risk management on 5/19/23. An attachment to the grievance dated 5/16/23, documented the following: 1. Narcotic Pill Inserted Vaginally and Causing Pain: This presents a serious risk as it may indicate incorrect medication administration or inappropriate behavior. It directly affects patient safety and comfort. It also raises legal and ethical questions. 2. Poor Social Engagement and Rude Behavior: While not directly a physical safety issue, poor social engagement and rude behavior can have a serious impact on patient mental wellbeing. It can also be indicative of larger problems with staff professionalism and training. It's also a risk to the reputation of the facility. 3. Argumentative and Verbal Behavior: This presents risk to the mental wellbeing of patients, and to the harmony of the work environment. Such behavior can lead to distress for the patient and a negative perception of the facility. 4. Schedule of Nurse [LPN #1] - Works Friday to Sunday: This is potentially a lower risk issue. However, if the patient's discomfort or complaints are specifically associated with [LPN #1], and he is consistently scheduled on certain days, this might inadvertently result in a predictable, recurring issue. The facility could also be seen as not responding to patient preferences and needs. The facility's policy, Abuse, Neglect and Exploitation, dated 8/26/22, stated the following: - Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. - Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. - An immediate investigation is warranted when instances of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur. - The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Resident #3's grievance was not identified as an allegation of abuse and investigated per facility policy. On 5/23/23 at 2:07 PM, the SSD and Administrator were interviewed. The SSD said she received a grievance from Resident #3 on 5/16/23. She said they treated Resident #3's allegations as a grievance due to Resident #3 not liking how the medication was administered. She said the IDT met and discussed the administration of the medication and education with LPN #1. The Administrator stated he saw it as an incorrect medication administration procedure. On 5/23/23 at 2:30 PM, the DON said she received a grievance regarding Resident #3 on 5/16/23. She stated she and the SSD asked Resident #3 if she was willing to work with LPN #1 again. The DON said Resident #3 stated she did not feel like she had a choice. The DON said she told Resident #3 she did have a choice, but there would be times when she would need a nurse and he would be the only one available. On 5/23/23 at 2:45 PM, the Administrator reviewed the facility's policy for abuse and neglect. He stated he felt the vaginal medication administration was a procedural issue. When the surveyors reviewed Resident #3's grievance with the Administrator regarding LPN #1's roughness resulting in vaginal bleeding, the disciplinary discussion with LPN #1 regarding poor social engagement and argumentative and verbal behavior, Resident #3's subsequent statements to the SSD and DON about not having a choice to have LPN #1 care for her, the Administrator agreed the grievance should have been reported as potential abuse. The Administrator also said there was no documentation of the allegation in Resident #3's record or documentation of the conversations with the SSD and DON. When asked why Resident #3's grievance was not included in the grievances requested by the surveyors, he stated it was not provided as it was still in progress. On 5/23/23 at 5:18 PM, the Administrator, DON, and CNO were notified verbally and in writing of an Immediate Jeopardy (IJ) determination at F600 related to the facility's failure to ensure residents were free from abuse. This failure placed Resident #3 at increased likelihood for serious harm. On 5/23/23 at 5:23 PM, the facility provided a plan to remove the immediacy which was accepted. The facility's IJ removal plan included: - An abuse allegation investigation was initiated per facility policy. - Interview of all appropriate residents to determine scope of potential harm to other residents. - Suspend accused staff member pending investigation and substantiation/un-substantiation of accusations to prevent the potential for further harm to residents. On 5/23/23 at 5:23 PM, the Administrator, DON, and CNO were verbally notified the immediacy was removed based on onsite verification the IJ removal plan was implemented. Following the removal of the immediacy, noncompliance remained at a scope and severity of G, constituting actual harm that is not immediate jeopardy. From 6/12/23 to 6/14/23, the survey was extended after review of the facility's investigation uploaded to the State Agency's Long-Term Care Reporting Portal on 5/26/23 with the facility's documented determination the abuse to Resident #3 was unsubstantiated and LPN #1's potential continued access to Resident #3. Additionally, another investigation was uploaded to the State Agency's Long-Term Care Reporting Portal on 5/30/23 by the facility relating to Resident-to-Resident verbal abuse that occurred on 5/23/23 and upon receipt and review of these reports, it was determined further investigation was necessitated to rule out further immediate jeopardy in the facility. Additional findings include: On 5/26/23, the facility uploaded the investigation of Resident #3's allegation of abuse by LPN #1 to the State Agency's Long-Term Care Reporting Portal, after it was identified on survey. The investigation included the following documentation: a. Interview questions conducted by the Administrator with Resident #3 documented the following: - Administrator: Do you feel safe here at [the facility]? - Resident #3: Yes, except for [LPN #1]. - Administrator: Have you been abused by another resident or staff member? - Resident #3: Only him (referring to [LPN #1]). - Administrator: Do you feel like what occurred was abuse? - Resident #3: Yes, it was painful. He shoved it [the medication] up there [in the vagina] so high. That had never happened before. I yelled out in pain, and he said, 'that shouldn't be painful.' b. Interview questions conducted by the Administrator and DON with CNA #1 who LPN #1 said was in the room with him and Resident #3 at the time of the administration of her vaginal medication, documented the following: - Administrator/DON: Are you aware of an incident on 5/13/23 involving [LPN #1] and [Resident #3]? - CNA #1: Yes. - Administrator/DON: Did you witness the incident? - CNA #1: Yes - Administrator/DON: In your own words, describe the incident in question. - CNA #1: I went to answer [Resident #3's] call light and he [LPN #1] came in behind me to give her her [sic] pill in her vagina. I stayed to change her brief after he's done. He [LPN #1] told her [Resident #3] he was going to put the pill in. Tried once and couldn't, and tried a second time. She started saying 'it's hurting'. - Administrator/DON: Was she yelling out in pain or telling him? - CNA #1: No yelling, telling him 'it hurts, it hurts'. He was telling her 'It's okay, it's normal to be hurting'. - Administrator/DON: What did you think about what was happening? Did anything about the situation seem different than normal? - CNA #1: I saw that he wasn't gentle like I've seen others do it, and they are more gentle. - Administrator/DON: Can you say more about what you mean? - CNA #1: When he inserted two fingers to try again, she said it was hurting, and he kept going. On 6/13/23 at 5:15 AM, CNA #1 was asked by the state surveyors if she witnessed the vaginal medication administration on 5/13/23 to Resident #3 by LPN #1. CNA #1 said she was present to assist with Resident #3's positioning and stayed after the procedure to help her with her adult briefs. CNA #1 stated Resident #3 screamed several times that it [insertion of the medication] hurt. She stated LPN #1 did not pause and kept going. She said Resident #3 had an indwelling urinary catheter at the time. CNA #1 stated she did not observe bleeding in Resident #3's vaginal area prior to insertion of the vaginal medication by LPN #1. She said when she changed Resident #3's brief after the procedure there was bleeding in the vaginal area. On 6/13/23 at 1:30 PM, Resident #3 stated she did not want LPN #1 ever coming into her room and another nurse administered her medications when she needed them when LPN #1 was present on night shift. On 6/14/23 at 8:38 AM, LPN #1 was interviewed by the surveyors via phone. When asked if Resident #3 complained of pain during the procedure, LPN #1 stated if someone was yelling out during a procedure he would stop and assess the situation. LPN #1 said he did not recall Resident #3 yelling out but that he was very focused on completing the procedure. The facility failed to ensure Resident #3 was protected from physical and mental abuse. 2. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including Guillain-Barre Syndrome (a rare disorder in which the body's immune system attacks the nerves which can result in lasting effects, such as weakness, numbness, or fatigue), Myelopathy (injury to the spinal cord which can cause nerve dysfunction along the spinal cord resulting in pain, loss of balance and coordination and numbness in the area around the compression point). Resident #7's care plan, initiated 2/11/22, stated Resident #7 had a history of aggressive symptoms of being antagonistic to other residents. Interventions included: - Resident #7 utilized counseling services and was practicing tools on how to be respectful to others and staff were to remind him to be respectful of others, initiated on 2/18/22, and revised on 3/6/23. - If Resident #7 was observed to initiate any potential form of abuse such as taunting, belittling, hitting, or badgering to another resident staff were to immediately ensure the safety of Resident #7 and all residents and directly notify the facility abuse coordinator, initiated 2/11/22, and revised on 5/12/22. These interventions were not followed. a. An investigative summary uploaded to the State's Long-Term Care Reporting Portal, dated 5/30/23, documented an investigation of a verbal altercation between Resident #7 and Resident #6. The investigative summary documented Resident #7 was the alleged initiator of the verbal altercation and Resident #6 was the alleged receiver of the verbal altercation. The summary documented Resident #7 and #6 had attended a facility activity of going shopping and it was alleged Resident #6 requested the country music be turned off [on the facility bus] as it made him tearful. Resident #7 allegedly became upset stating the music should not be turned off for one individual. The summary documented per witness statements and Resident #7 and Resident #6's recollection of the event, a verbal altercation then took place and ended with Resident #6 calling the police. The investigative summary, dated 5/30/23, further documented, On this day, the facility implemented an all-resident interview process to assure the safety, emotional, and psychosocial wellbeing of all residents. In doing so it was identified that [Resident #7] has unfortunately recently had negative, verbal interactions with other residents. These findings warranted the facility to take further immediate action by placing a staff member to be in direct line of sight of [Resident #7] to observe verbal interactions with others to ensure resident safety and well-being. The all-resident interviews, dated 5/24/23, included the following additional allegations of verbal abuse from Resident #7: i. Resident #6 stated he did not feel safe in the facility and said another resident harrassed him verbally. On 6/14/23 at 10:08 AM, Resident #6 was interviewed about his interaction with Resident #7 on the bus after the field trip to the store on 5/23/23. Resident #6 stated country music was a trigger for sadness to him related to his ex-wife. He stated he very nicely asked the bus driver to turn the music off. He stated Resident #7 said it shouldn't be turned off for one person and called him a cry baby. Resident #6 stated Resident #7 was constantly badgering him, calling him names and bullying. He stated Resident #7 called him whiny and always made derogatory remarks to him whenever he encountered him. Resident #6 said he usually says nothing in response, but because Resident #7 kept calling him names on the bus and continued when they got off the bus back at the facility, he couldn't take it anymore and told Resident #7 he was going to call the police if he didn't stop. Resident #6 said Resident #7 did not stop so he called the police. Resident #6 said he told the Administrator when he saw Resident #7, he went the othr way and avoided activities Resident #7 attended. Resident #6 further stated Resident #7 bullies everybody and never has anything nice to say. ii. Resident #11 stated [Resident #7] called me a bitch and fat pig when passing by him. An incident, dated 5/24/23, uploaded to the State's Long Term Care Reporting Portal, documented Resident #11 reported Resident #7 addressed her with an inappropriate epithet upon entering through the front doors [of the facility]. Resident #11 reported she was verbally insulted, leading to feelings of anger, frustration, rejection, and awkwardness. The investigation summary of the incident documented: Post-incident, Social Services conducted an interview with [Resident #11]. She expressed her preference to avoid socializing with [Resident #7] and continue her interactions with other residents and staff. The investigation summary further documented, A subsequent follow-up was done with each resident to ensure their safety. [Resident #11] reported feeling safe at [the facility], knowing exactly who to report any safety concerns to. However, she did express feeling verbally harassed by [Resident #7], citing instances of him addressing her with derogatory remarks . The investigation's final verdict stated, Upon completing our investigation, it was found that the incident resulted from a mutual state of annoyance between the residents involved. [Resident #7], in particular, demonstrated a lack of restraint in expressing his annoyance, resorting to offensive language when agitated. Interviews conducted with other residents further substantiated this behavior, revealing a pattern that led to several residents perceiving [Resident #7] as a bully. iii. Resident #6 stated he did not feel safe in the facility. He stated he had been abused by another resident verbally. iv. Resident #10 stated she had not currently been abused by another resident or staff member but stated When I first got here [Resident #7] was very mean to me, said the worst swear words I have ever heard. I just avoid him because I don't want him to say anything else to me. v. Resident #5 stated he did not feel safe in the facility. He stated he was verbally harassed by another resident. On 6/13/23 at 11:16 AM, Resident #5 was interviewed by the state surveyors. Resident #5 stated he felt angry when he saw Resident # 7. He stated he made noises and comments to get a rise from him. Resident #5 said Resident #7 bothers other residents and they were scared of him. Resident #5 further stated Resident #7 intimidated residents. vi. Resident #12 stated he was abused by another resident and stated, That guy [Resident #7], he calls me names .Big Baby On 6/12/23 at 4:41 PM, the Administrator stated he did not feel Resident #7 was abusive, but more annoying. He stated Resident #7 said things to get a reaction, but residents said it was not abuse. When the facility's policy with the definitions of abuse and willfulness were reviewed with the Administrator, he agreed the allegations for Resident #7 should be reported and investigated and stated he had learned a lot since these incidents. The Administrator agreed Resident #7's comments fit the definition of abuse based on review of the facility policy. b. A progress note, dated 1/3/23 at 7:00 PM, documented Resident #13 [unidentified in the note] from room [ROOM NUMBER] was next to RN #1 at the nurse's station keeping her company as they waited for the CNA to get her to bed. The note documented Resident #7 came over and told Resident #13 to get out of the way in a mean, loud tone. The note documented before Resident #7 came closer to them, Resident #13 told RN #1 she didn't want to be here if he was coming over. The note documented Resident #13 acted scared of Resident #7. When RN #1 asked Resident #13 about it, she stated he says mean things to me. During an interview on 6/12/23 at 4:41 PM, when asked about the progress note and the incident between Resident #7 and Resident #13, the Administrator said there was no grievance or reportable about the altercation, and he was unaware of the incident. The facility failed to ensure Residents #5, #6, #10, #11, #12, and #13 were free from verbal and mental abuse.