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Based on interview and record review, the facility failed to ensure swing bed patients were free from involuntary seclusion, and verbal abuse, that allegations were being reported, and staff were trained in swing bed patient rights and abuse for 4 (#s 1, 2, 4 and 6) of 7 sampled swing bed patients and supplemental swing bed patients.

Findings include:

1. Please refer to C-382; the facility failed to ensure swing bed patients were free from involuntary seclusion and verbal abuse for 2 (#s 1 and 2) of 7 sampled swing bed patients and supplemental swing bed patients.

2. Please refer to C-384; the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, were reported immediately to the State Agency for 4 (#s 1, 2, 4, and 6) of 7 sampled swing bed patients and supplemental swing bed patients.

Based on interview and record review, the facility failed to ensure swing bed patients were free from involuntary seclusion and verbal abuse for 2 (#s 1 and 2) of 7 sampled swing bed patients and supplemental swing bed patients.

Findings include:

1. During an interview on 7/13/16 at 1:45 p.m., the family member of swing bed patient #1 said, "They told her (swing bed patient #1) she couldn't come out of her room. She just obeys authority. They would tell her she is bad and would have to stay in her room."

Swing bed patient #1's diagnoses included cerebral atrophy, depression, post-head injury and schizophrenia.

Review of a progress note for swing bed patient #1, dated 6/1/16, showed, "Pt continues to lash out at staff and residents. Pt. yelling and slamming doors. Pt. called from room asking if she could come out for lunch. Pt. was told that she needed to eat in her room due to her behavior. Pt. then yelled at staff. When Pt. tray was delivered to room, Pt. kicked the tray then kicked at the bedside table where the tray was being set. Pt. was told not to do that, Pt. then yelled at staff and Pt. was then told that she is to stay in her room the remainder of the day. Continue to monitor." This note was entered by staff member B.

Review of a progress note for swing bed patient #1, dated, 6/9/16, showed, "Throughout the day Pt had numerous outbursts toward staff and each time was told to go to her room and calm down. Each time the Pt came out of her room she would yell at staff. Pt would slam her walker on the floor several times prior to then going to her room and slamming the door. Continue to monitor." This note was entered by staff member B.

Review of a "Patient and Visitor Grievance/Complaint Investigation Report Form" dated 6/9/16, showed the family member of swing bed patient #1 filed a complaint that "Staff do send resident to her room, but usually to calm down due to escalation and possible threat to self, staff, or other residents..."

Review of a progress note regarding swing bed patient #1, dated 5/31/16, showed, "...Pt. then started yelling at staff stating that 'you are all assholes.' Pt was asked to go to her room. Pt got up, slammed the walker on the floor and then walked to her room. Pt then slammed the door to her room all while continuing to yell at staff. Continue to monitor." This note was entered by staff member B.

Review of a progress note regarding swing bed patient #1, dated 5/19/16, showed, "...Pt is instantly angry when she doesn't get her way. Pt has slammed her plate on her table, thrown her silverware at her tablemate, thrown her walker at staff, refused to turn down a television that was on max volume and when the television was turned off, she cussed at the staff. Stating that, 'you are all assholes.' Pt has been sent to her room each time to cool off and each time the pt comes out of the room and continues to yell at staff. Continue to monitor Pt." This note was entered by staff member B.

In an interview on 7/14/16 at 8:15 a.m., staff member H said "the nurse (staff member B) sent (swing bed patient #1) to her room. She was never gotten out. She had her meals in her room. Never saw anybody in the bedroom with her. There were other times she was sent to her room. I have spoken to (staff member A) and she said she would take care of it. I have spoken to both (staff member A) and (staff member C) about the things (staff member B) has said to resident #1. It was an order to go to your room. (Staff member B) would take (resident #1) her lunch to her in her room and would tell the other staff 'she's going to stay in her room and she's not coming out for games.' (Staff member C) knew she was in her room all day. (Staff member A) knew (staff member B) had ordered (resident #1) to her room. I have reported several things in the past and I am the bad person. It feels like hitting a brick wall if I say anything."

In an interview on 7/14/16 at 11:20 a.m., with staff members I, K, and L, staff member I said "(swing bed patient #1) was sent to her room all day. If (swing bed patient #1) tried to come out the nurse would order her back."
-Staff member L said "The nurse would point and say get back to your room. They antagonized her, talked down to her. Treated her like a three year old. If you talk to her calmly she will calm down. (Staff member M) has assisted (staff member B) in keeping her in her room. (Staff member B) has a bad attitude. They (staff member M and B) back each other up. It was in June that (swing bed patient #1) was sent to her room.
-Staff member K said, "Its been more than once that (swing bed patient #1) had been put in her room. More than one time in last six months."
-Staff member I said "I have talked to upper management about this. I talked to (staff member A) just the other day."

In an interview on 7/14/16 at 10:27 a.m., swing bed patients #3 and #4 said, "We have seen staff tell resident (swing bed patient #1) have to go to room several times. (Staff members B, N, and M) made (swing bed patient #1) stay in her room for a week. They ordered (swing bed patient #2) to her room. She (swing bed patient #2) was angry. (Swing bed patients #1 and #2) were provoked by staff. They nitpicked them on things they wanted like condiments. They reacted to (swing bed patients #1 and #2) and it was loud enough it could be heard all over the dining room. They picked on (swing bed patients #1) more than (swing bed patient #2). (Swing bed patient #1) was a messy eater and she was doing things staff didn't like. They would look for ways to provoke her so they could order her to her room. There were several times they ordered her to her room. We have heard (staff member B) say insulting things to residents. They denied her (swing bed patient #1) more water and this would anger her."

In an interview on 7/13/16 at 3:30 p.m., swing bed patient #5 said "They ordered (swing bed patient #1) to her room."

In an interview on 7/14/16 at 12:15 p.m., staff member A said "I didn't find any evidence of (swing bed patient #1's) family being informed of being sent to her room."

In an interview on 7/14/16 at 12:15 p.m., staff member C said "I had a meeting with (swing bed patient #1's) family but didn't discuss her being sent to her room."

Review of swing bed patient #1's Care Plan showed the goal of not harming self or others. The interventions included "If behavior is escalating encourage resident to take a nap, watch television or a movie, take a walk, do a puzzle. Remove resident from potentially agitating situations." The plan did not show evidence of confining nor ordering the swing bed patient to her room.

Review of the facility's Policy titled "SBS 01.10 Swing Bed Abuse and Neglect" showed "to provide Resident's the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriate of property... Involuntary Seclusion is defined as a separation of a resident from other people and/or from his/her room and/or confinement to his/her room, (with or without roommates), against the resident's will, or the will of the resident's legal representative. Emergency or short term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited period of time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident's needs."

Review of the facility's "Patient Rights and Responsibilities" showed "As a patient of [name of facility], you have the right: To every consideration of privacy and be free of restraints and involuntary seclusion unless medically necessary."

2. In an interview on 7/13/16 at 3:07 p.m., swing bed patient #2 said "(Staff member B) ordered me to stay in my room. Said I was talking about (swing bed patient #1). When (name of ombudsman) came I told her that I had to sit in the back of the dining room by myself. (Staff members B and C) said I would have to sit back there by myself. I told them I would just go to my room."

Resident #2's diagnoses included depression.

Review of a progress note for swing bed patient #2, dated 5/3/16, showed, "Pt. was reminded that if she is going to converse with the other resident they must sit in the bird room due to the behavior toward the other residents in the dining room. Pt. started yelling at this nurse about 'I am going to get you, I am going to get you all fired. I hate it here.' Pt was again calmly reminded to go to her room or the bird room if she wants to converse with this other resident. The other resident refused to leave the dining room and told the Pt, 'I don't want to sit with you now, you are not talking nice to anyone.' The Pt then started banging her walker and yelling at this other resident and this nurse and was again reminded that she cannot act in this manner. Pt did leave the dining room and was escorted to her room. Pt then yelled again, 'You just wait, I am going to get you all fired. I am calling my son and my brother who is on the board an you'll be sorry.' Pt was again calmly reminded to sit in her room until she is (sic) calmed down. Pt then slammed the door. Continue to monitor Pt behavior." An addendum to this note showed "pt son called stating that his mom called stating that 'we are mean and won't do anything for the (sic) her and make her sit alone..." This note was entered by staff member B.

Review of a progress note for swing bed patient #2, dated 4/13/16, showed, "Pt was sitting at the wrong table at lunch. Pt was again reminded to sit at the assigned table for the safety of all the residents. Pt again ignored the nurse. 1520 (3:20 p.m.)-Called to another patient's room in regards to this patient telling the other patient that 'you don't belong at this table, just leave, you are so stupid.' The other patient was very upset and went back to her own rom. This nurse (staff member B) and (staff member M) went to see the patient. Pt was asked nicely to go back to her room for (sic) she can't treat other residents in this way. Pt started yelling at this nurse. Pt was reminded to not yell and disrespect the staff and other residents. Pt was also reminded that if she wants to sit with the other table mate that they will have to go to the bird room for (sic) they can't sit at this table anymore. Pt did get up but continued to yell at this staff. As patient was walking back to her room Pt was yelling, 'you trouble making bitches.' Continue to closely monitor patient and behavior." This note was entered by staff member B.

Review of swing bed patient #2's Care Plan showed no evidence of goals nor interventions to address maladaptive behaviors.

3. a. At the time of the exit, the facility presented a sign in sheet of staff that had attended an abuse training. Review of this nursing sign in sheet had the hand written date of 11/18/15 at the top with the words "resident rights and Abuse." This sign in sheet showed that staff member B and M had not signed in.

In an interview on 7/14/16 at 12:00 p.m. , staff member C said she did not know allegations had to be reported before the investigation was completed.

b. In an interview on 7/14/16 at 11:20 a.m., with staff members K, I and L, staff member L said staff member B told them (staff member K and I and L) and kitchen staff (in regards to swing bed patient #3 wanting to go along to the appointment with resident #4) "Her ass isn't going." Staff member N was in there who is a family member of swing bed patients.

In an interview on 7/14/16 at 3:20 p.m., staff member P said "(Swing bed patient #2) wanted some more food. I (staff member P) went to staff member B to ask if that was ok and staff member B went to resident #2 in the dining room where other residents could hear and told her "I already told you, you fuckin can't have that." In November 2015 everybody in the building was interviewed by HR. I (staff member P) told (staff member D) what I (staff member P) heard (staff member B) say to (swing bed patient #2)."

In an interview on 7/14/16 at 4:00 p.m., staff member D said "It was not in November but January 2016 when I (staff member D) did the investigation based on an anonymous letter indicating that vulgarity was being used in the residents presence. (Staff member P) did tell me about (staff member B). I (staff member D) went to (staff member C) about this who was to start a coaching file on (staff member B)."

Review of the anonymous letter (that was not dated) showed that it was to the attention of the CEO and showed "I feel the need to bring this to your attention that (staff member B) has been conducting herself in an unprofessional manner. Not only have I heard staff complain, but residents as well. I have become witness to her behavior myself, I witnessed her yelling at residents to the point of them being intimidated and afraid. They will not come forward out of fear of retaliation by (staff member B). I have been told of her using vulgarity in the residents presence and have myself been subject to her verbal abuse and hostile behavior. Residents and staff are afraid of her. Not only does she create a hostile work environment but her bullying ways are making residents afraid of her. My personal opinion to hell with staff, please address your residents needs."

Review of the document titled "Performance Issues" received from staff member D showed on 1/5 and 6/16, staff member A and staff members F and D interviewed 22 staff and 8 residents. "Although there is a disjunction between the views of staff and residents, the sheer volume of documentation regarding perceived bullying leads me to recommend the following: 1. Begin the coaching/discipline process with (staff member B) for inappropriate behavior."

In an interview on 7/14/16 at 4:00 p.m., staff member D, said staff member B has not been suspended with or without pay nor reassigned to non-patient contact work in the past eight months.

Based on record review and interview, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse were reported immediately to the State Agency for 4 (#s 1, 2, 4, and 6) of 7 sampled swing bed patients and supplemental swing bed patients.
Findings include:

The following allegations of abuse and neglect were not reported to the State within 24 hours:

a. Review of Resident Council note dated 4/27/16, showed "Resident said that (resident #6) another resident was hollering help me after dinner and he went up and told the staff that (resident #6) needed help and they just sit there and said oh hes (sic) hollering again. Resident couldn't reach his call light either. Resident said he was in pain and needed some help."
Staff were present at this meeting including staff member A.

b. Review of a progress note, dated 5/3/16, showed swing bed patient #2's son called to report his mother reported to him "we are mean and won't do anything for the (sic) her and make her sit alone,..."

c. Review of a progress note dated 5/27/16 showed that "Staff member reported that patient (swing bed patient #4) felt 'retaliated' against after a complaint regarding a nurse during resident council."

d. Review of Resident Council note, dated 6/27/16, showed "Resident said when she turns her light on they come in and turn it off and never come back ....Resident said that she has some sores on her head and needs to have some oedication (sic) put on it. There is 2 nurses that bring it in put (sic) on the table and will tell her there you go. I told them I don't know where the sores are at they (sic) will leave anyway."

e. Review of Resident Council note, dated 5/25/16, showed "Resident said that another resident was scared, because some staff holler at her."

f. Review of a "Patient and Visitor Grievance/Complaint Investigation Report Form" dated 6/9/16, showed the family member of swing bed patient #1 filed a complaint that "Staff do send resident to her room, but usually to calm down due to escalation and possible threat to self, staff, or other residents..."

g. In an interview on 7/14/16 at 4:20 p.m., staff member G said "I did meet with the ombudsman the day before yesterday. She brought some generalized concerns to me. She did say residents were afraid of retaliation. She said this could constitute abuse. She volunteered two names that came up frequently as verbally abusing residents were (staff members B and D). I have not reported. I do not know what the reporting requirements are for verbal abuse. I wanted to get the CEO in on this. We met with the ombudsman today at 3:00 p.m."

In an interview on 7/14/16 at 1:45 p.m., staff member A said there was only one incident reported to the State in the last 12 months.
Review of this incident showed swing bed patient #7 reported to "some church folk" that "they are abusing me."