F0600

E

Failure to Investigate and Act on Abuse Allegations Against Contracted Phlebotomist

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from abuse and to report, investigate, and act on allegations of abusive conduct by a contracted phlebotomist. On the date in question, a cognitively intact resident with a left artificial knee joint following joint replacement surgery reported that a male phlebotomist entered her room around 4 a.m. without introducing himself, without a name badge or identification, and proceeded to draw blood despite her questions about who he was and why the blood draw was needed. She stated he did not use a tourniquet and inserted the needle in a forceful, stabbing manner that caused significant pain. According to nursing progress notes and her interview, she verbally told him to stop, yelled at him to stop the procedure, and felt her rights were violated when he continued to re‑insert the needle, causing her anguish and anxiety and contributing to her decision to leave the facility against medical advice.

A second cognitively intact resident with spinal stenosis also reported rough, unprofessional conduct by the same phlebotomist on more than one occasion. She stated that during a prior blood draw, he did not identify himself, did not knock, pulled the curtain open, held her arm down despite her telling him she had small veins and that it hurt, and told her to “cool off.” She reported that his technique was poor, that he used a stabbing technique, and that her arm was bruised for a week after the first encounter. When he returned early in the morning on the same date as the first resident’s incident, again without acknowledging himself, she told him to get out and refused to allow him to draw her blood. She reported these concerns to nursing staff, including that she had been a certified phlebotomist for 25 years and believed his technique inflicted unnecessary pain.

Multiple staff members were aware of the residents’ complaints but did not ensure that the allegations were treated and processed as potential abuse in accordance with the facility’s abuse and neglect policy. Nursing progress notes documented that staff were aware of the first resident’s complaints and told her the phlebotomist would be reported to the core lab company administrator, but there was no documented evidence of immediate action to ensure resident safety or to prevent the phlebotomist from continuing to provide services. The registered nurse supervisor, case manager, charge nurse, and director of staff development all acknowledged receiving complaints or hearing about the phlebotomist being rude, harsh, or having “heavy hands,” yet the charge nurse did not report or further investigate, and the case manager only provided limited information to the administrator. The registered nurse supervisor stated she attempted to call the core lab to identify the phlebotomist but did not document or follow up thoroughly. As of the survey date, there was no record that the facility had identified the phlebotomist, investigated the concerns of the two residents, or notified the contracted laboratory company, and no interventions had been implemented to prevent further incidents, despite the facility’s written policy requiring investigation of alleged abuse and neglect to clarify what happened and identify possible causes.

The second resident’s refusal to allow further blood draws from the phlebotomist led to a delay in necessary lab work, treatment, and diagnosis. Staff interviews confirmed that the phlebotomist typically arrived before the start of the morning shift, that some staff were unfamiliar with his identity, and that communication with the vendor was acknowledged as an area needing improvement. The director of nursing stated he was unaware of any issues with the contracted phlebotomist and emphasized that residents can refuse blood draws and that poor service or delays in blood draws may risk delayed care. Despite these acknowledgments and the facility’s abuse and neglect policy defining abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and neglect as failure to provide necessary services to avoid physical harm, pain, mental anguish, or emotional distress, the facility did not initiate or document an abuse investigation into the phlebotomist’s conduct toward the two residents.