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Based on interview and record review, the facility failed to prevent neglect on September 28, 2007, when one certified nurse attendant (CNA) did not change disposable briefs for four of her assigned patients on the night shift. The facility failed to prevent verbal abuse to one assigned patient by the same CNA on October 8, 2007, on the night shift.

Findings

On October 10, 2007, the facility self-reported that CNA 1 failed to change disposable briefs for her assigned patients on September 28, 2007 for nine hours. The self report stated the facility became aware of the incident on October 1, 2007. On October 8, 2007 Patient (Pt) A reported that CNA 1 did not answer her call light in a timely manner. Additionally, CNA 1 reportedly told Pt A to, "Stop it right now", because Pt A turned on her call light for her roommate on that same date.

On December 13, 2007, at 3 PM, the personnel file of CNA 1 was reviewed with the Director of Nurses (DON). CNA 1 was hired on April 4, 2006, was put on administrative leave October 10, 2007, and resigned on October 19, 2007. On June 28, 2007, CNA 1 was counseled about not changing her assigned patients' disposable briefs during her June 20, 2007 shift, and that she refused to do the 4 AM rounds on her assigned patients. Included in this written disciplinary warning was an incident dated April 16, 2007 regarding not changing the patients' disposable briefs during her shift. A "Final Written Warning" was checked on the "Disciplinary Action Form." On September 7, 2007, a Disciplinary Action Form that again included a "Final Written Warning" notation was filled out for CNA 1 for being a 'no show' and allowing her CNA certificate to lapse.

On January 14, 2010 at 11:30 AM, the Human Resource Director (HRD) was interviewed. She stated that she became aware of the incidents of September 28, 2007, neglect, and the verbal abuse of October 8, 2007, on October 10, 2007. The HRD had been told of the incidents by the DON, who is no longer employed by the facility. The HRD was asked why CNA 1 had not been placed on administrative leave on October 1, the day the facility was aware of the September 28, 2007, incident. The HRD stated, "The investigation of the incident was the DON's responsibility. As soon as she informed me of the incidents on October 10, 2007, we suspended her." CNA 1's time sheet documented she worked on October 2, 3, 4, 5, 6, 8 and 9, 2007.

On January 14, 2010, at 12:20 PM, the Assistant Director of Nurses (ADON) was interviewed. The ADON stated that she was made aware by CNA 2 of the September 28 incident on October 8, 2007. The ADON wrote the incident up on the same date. In the process of investigating the incident, the ADON interviewed Pt A and learned of the verbal abuse by CNA 1 on that date. The ADON gave the write-up to the DON on that day. The ADON was asked who else was aware of the incident on October 1. The ADON stated that, to her knowledge, only CNA 2 was aware of it on October 1. CNA 2's personnel file was reviewed at this time. The Abuse Reporting Requirement Training form documented that CNA 2 had received the training on March 31, 2005.

On January 25, 2010 at 4 PM, CNA 2 was interviewed. She stated that she came to work "on the date CNA 1 didn't change her patients' briefs", but was unable to identify the specific date. "CNA 1 gave me report from the night shift and said she had changed each patient's disposable briefs. What we do is write on the brief in black permanent marker the date, time and your initials when you change them. I even asked her, 'even room 8?' Because room 8 is a little off to itself. She said she changed all four of the patients in room 8. When I got into the room, none of the briefs had been changed on the night shift. I went to LVN 1, who worked the night shift. I told her and she came into the room to see for herself. We immediately changed each patient. I believe LVN 1 wrote CNA 1 up."

On January 26, 2010 at 2 PM, LVN 1 was interviewed. She stated that she remembered CNA 1 and that was a question of whether or not she changed patients' briefs on her shift. But she did not remember specifically any time that she was made aware of the issue nor did she ever notify administration of any incident.

Based on interview and record review, the facility failed to follow its policy and procedure regarding abuse reporting and investigating requirements.

Findings

On October 10, 2007 the Director of Nurses (DON) self-reported to the Department that CNA 1 neglected to change disposable briefs on four patients during her night shift on September 28, 2007. Investigation was begun by the DON on October 1 and completed on October 10, 2007. During the time of the facility's investigation, another incident occurred on October 8, 2007. Pt 2 reported that CNA 1 did not answer her call light in a timely manner. When CNA 1 did answer the call light initiated by Pt 2 for her roommate, CNA 1 instructed Pt 2 to "Stop it right now."

The policy: "Abuse Prevention Program---Definition of Abuse" was reviewed on January 14, 2010, at 4 PM. It defined abuse as inclusive of the terms "neglect and mistreatment." The policy read: "Verbal abuse refers to any use of oral...language that includes disparaging terms to patients....Physical abuse includes....deprivation." Reviewing the policy "Abuse Prevention Program Mandatory Investigation and Reporting Requirements", reads: "a. Protection of Patient/Resident from further abuse. When allegation of abuse, neglect, mistreatment....the subject of the allegation will be immediately removed from patient/resident care...until the investigation is completed." Regarding notification and Mandatory Reporting: "e. ...report to the Long Term Care Ombudsman of Kern County, the California Department of Health Services. This must be done within 24 hours of the occurrence of abuse or allegation of abuse."

CNA 1's personnel file was reviewed on December 13, 2007, with the DON and again on January 14, 2010, with the Human Resources Director (HRD). The file documented that in June of 2007, CNA 1 was counseled regarding failure to change patients' disposable briefs during her shifts on April 16 and June 20, 2007. There was no documentation in the file that CNA 1 was suspended while the April and June incidents were investigated, as according to the facility's policy. There was no documentation in the personnel file that these two incidents of neglect were reported to the Department of Public Health, the ombudsman program or the CNA Board. The self reported incident of October 10, 2007 documented that the facility administration was aware of the September 28 incident on October 1, 2007. CNA 1 was not suspended immediately or put on administrative leave as the policy and procedure outlined. CNA 1 worked seven more days, and on one of them, October 8th was verbally abusive to Pt 2.