F0600

D

Failure to Honor Resident Care Preferences and Prevent Alleged Staff Abuse

Los Angeles, California Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its abuse prevention and rules of conduct policies by assigning a CNA to provide care to residents who had requested not to receive care from that CNA, and by not honoring a resident’s expressed objection at the time of care. Resident 4, who has intact cognition and decision-making capacity and requires assistance with multiple ADLs due to hemiplegia, lack of coordination, and other medical conditions, had previously reported negative interactions with CNA4, including an incident where CNA4 forced a glove into the resident’s hand, applied A&D ointment to the glove, and told the resident to apply it herself. Resident 4 also reported that on a later night shift, CNA4 gave her a towel to clean herself, and when the towel fell to the floor and was picked up, CNA4 told her that next time it would be worse for her and stated, “I am from [NAME]; we do not play that in [NAME],” making the resident feel less than the staff.

On the night in question, Resident 4 told LVN2 at the beginning of the 11 p.m.–7 a.m. shift that she did not want CNA4 assigned to her. Despite this, LVN2 completed the staff assignment including CNA4, stating her understanding was that the only resident CNA4 could not be assigned to was Resident 5, who had previously requested not to have CNA4. RN1 confirmed that one staff member had called in sick and that CNA4 was assigned to Resident 4; RN1 acknowledged that Resident 4 did not want CNA4, but he asked Resident 4 to give CNA4 a chance, and both agreed to work together. CNA4 stated that LVN2 knew she could not work with Resident 4 but told her the assignment could not be changed, and that RN2, who usually made assignments and did not assign CNA4 to Resident 4, was on vacation.

During incontinent care for Resident 4 on that shift, an altercation occurred between Resident 4 and CNA4. CNA4 reported that Resident 4 requested another CNA, but LVN3 told the resident that due to short staffing she must allow CNA4 to change her. CNA4 stated that Resident 4 dried herself and then threw the dirty washcloth at CNA4, hitting her in the abdomen, and that Resident 4 kicked her in the stomach without provocation. Resident 4, however, told LVN3 and the Social Services Director that after she dried herself and gave the towel to CNA4, CNA4 became upset, accused her of throwing the towel, and then grabbed the same towel and threw it at Resident 4’s face, causing Resident 4 to feel abused and to kick CNA4 in self-defense. LVN3 corroborated that when she entered the room, Resident 4 and CNA4 were arguing, Resident 4 alleged that CNA4 hit her in the face with a towel, and CNA4 denied throwing the towel but stated that Resident 4 had hit her. The Administrator and SSD both acknowledged that Resident 4 reported CNA4 throwing the towel at her face and that there was a prior history between them.

The deficiency also involves the facility’s handling of Resident 5’s complaints about CNA4. Resident 5, who has severely impaired cognition and multiple medical conditions including non-Hodgkin lymphoma, osteoarthritis, and polyneuropathy, requires extensive assistance with ADLs and mobility. Resident 5 told CNA5 that he wanted to speak to a supervisor to report abuse, and CNA5 reported this to the charge nurse, supervisor, and Administrator. Resident 5 later stated that CNA4 grabbed his left arm, swung him to the left side, and was rude, and that he did not like how CNA4 turned him and that CNA4 did not communicate what she was going to do. The Administrator confirmed that Resident 5 stated he did not like the care he received from CNA4 and requested that CNA4 no longer be assigned to him, and that CNA4 was barred from caring for Resident 5 based on his preference. Despite this, LVN2 and other staff referenced confusion or incomplete awareness about which residents CNA4 could not be assigned to, and CNA4 herself stated that Resident 5 did not want her to care for him and that she was aware she was not allowed to have Resident 5. These events demonstrate that the facility did not consistently ensure that staff assignments and care practices honored residents’ expressed preferences and protected them from alleged abusive or disrespectful interactions, as required by the facility’s abuse prevention and rules of conduct policies.

In addition, multiple staff interviews revealed inconsistent understanding and communication regarding restrictions on CNA4’s assignments. LVN2 believed only Resident 5 could not be assigned to CNA4, while RN1 later learned from CNA4 that she was not supposed to be assigned to Resident 4. LVN3 stated she was unaware that CNA4 could not be assigned to Resident 4 until after the altercation, and also stated that CNA4 was not allowed to have Resident 5. The Social Services Director knew that CNA4 had been removed from caring for Resident 5 but did not know the reason or how Resident 5 developed bruising on his arm and fingers. The Administrator stated that if a resident does not want a staff member to care for them, staff should honor the resident’s request, and expressed concern about CNA4’s code of conduct and its effect on other residents. These facts collectively show that the facility failed to ensure that CNA4 was not assigned to residents who had requested not to receive care from her and failed to prevent situations that escalated into loud arguments and possible physical altercations, contrary to the facility’s abuse prevention and conduct policies.