F0552

E

Failure to Honor Residents’ Right to Refuse Rough Phlebotomy and Ensure Respectful Care

Los Angeles, California Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were treated with respect and dignity and that their right to refuse care from a contracted phlebotomist was honored during early-morning blood draws at the bedside. On the date in question at approximately 4:00 AM, a male phlebotomist from an outside laboratory company entered the shared room of two cognitively intact residents without introducing himself, wearing a visible name badge, or adequately responding when asked for his name. One resident, admitted with a left artificial knee joint following joint replacement surgery and assessed on the MDS as having cognitive skills for daily decision-making and needing varying levels of assistance with ADLs, reported that the phlebotomist stated he was going to draw her blood but did not explain who he was or why the blood draw was needed. She stated he proceeded to insert the needle in a forceful, stabbing manner without using a tourniquet, causing significant pain.

According to the resident’s account and nursing progress notes, she verbally told the phlebotomist to stop the procedure and yelled at him to stop, but he continued to re-insert the needle to draw her blood. She reported feeling that her rights were violated and that the incident caused her anguish and anxiety, contributing to her desire to leave the facility against medical advice. Her roommate, who also had cognitive skills for daily decision-making and was admitted with spinal stenosis requiring extensive assistance with ADLs, corroborated hearing the interaction, including the resident’s repeated requests for the phlebotomist to stop and her screams of pain. The roommate stated that the phlebotomist did not knock, did not identify himself, and pulled the curtain open when entering the room.

The second resident also reported having previously experienced rough and unprofessional blood draws by the same phlebotomist, including an earlier incident after which her arm was bruised for a week. She stated that he held her arm down despite her telling him it hurt, told her to “cool off,” and used a stabbing technique that caused significant pain, despite her informing him she had small veins and was a hard stick. On the later date, when he again entered around 4:00 AM without identifying himself, she told him to get out and refused to allow him to draw her blood, even when a male nurse accompanied him and asked her to permit the blood draw. Nursing progress notes documented that she adamantly refused the blood draw and that the CN attempted to convince her to proceed, but there was no documentation of honoring her refusal through appropriate follow-up per policy.

Facility staff were aware of both residents’ complaints about the phlebotomist’s rude, harsh, and rough conduct, as reflected in nursing progress notes and staff interviews. The RN Supervisor, CN, Case Manager, and Director of Staff Development all acknowledged being informed of concerns about the phlebotomist’s behavior and the residents’ reports that he did not identify himself and caused pain. Despite this, there was no documented evidence that the facility took immediate action to ensure resident safety, to prevent the phlebotomist from continuing to provide services to other residents, or to initiate an investigation to identify the phlebotomist and notify the contracted laboratory company. The RN Supervisor stated she attempted but was unable to reach the core lab to identify the phlebotomist and did not document or thoroughly follow up, and the CN did not report or investigate the incident after hearing the second resident’s complaint. As of the survey date, no investigation or interventions had been implemented, despite facility policies stating that residents are to be treated with respect, be free from abuse, be informed of and participate in treatment decisions, and that refusals of care must be assessed and addressed by the CN or DON without coercion or intimidation.