Sutter Care at Home

“Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This Element is not met as evidenced by: Based on interview and record review the Home Health Agency Licensed staff did not respect the rights of 2 of 2 sampled patients (Patient 1 and 2) when Occupational Therapist 1 (OT 1) spoke loudly and in a derogatory manner to Patients 1 and 2. This resulted in unnecessary emotional distress for Patients 1 and 2. Record review of the document “Your Guide to Home Health Care” (not dated) showed admitted patients had the right to “Have your property and person treated with respect.” Record review of the document “Home Health ROC Plan of Care” dated 7/12/2025 showed Patient 1 was alert, oriented, cognitively intact with no behaviors. Record review of the document “Home Health Plan of Care” dated 7/27/2025 showed Patient 1’s Diagnoses included Amyotrophic Lateral Sclerosis. (or ALS: progressive neurodegenerative disease that attacks nerve cells) Record review of the document “SBAR” (not dated) showed, on 8/13/2025 Patient 1 had reported an incident to the Agency regarding OT 1. Patient 1 stated OT 1 had raised his voice and instructed, “Stop! Don’t move until I say so.” Patient 1 expressed dissatisfaction with the interaction and requested reassignment to a different clinician. During an interview on 1/6/2026 at 9:10 a.m. Patient 1 stated OT 1 was “Rude and would not listen.” Patient 1 stated OT 1 invalidated things he would say, offended him and “Told me what I was supposed to say or feel.” At one point Patient 1 stated OT 1 had told him to “Shut up” and he was the “One talking now.” In a concurrent interview Family Member 1 (FM 1) stated it had happened several times and she felt it had “Crossed over to verbal abuse” as she was concerned since Patient 1 was “Vulnerable.” Patient 1 stated he felt “Patronized and abused.” Patient 1 stated OT 1’s voice was extremely loud, almost shouting and it felt as if it were his way to “Assert dominance.” FM 1 stated she had asked OT 1 why he was talking like that to Patient 1. FM 1 stated OT 1 denied yelling and told her he had been doing this work for a long time and he “Knew what he was doing.” During an interview on 1/14/2026 at 5:16 p.m. OT 1 stated he and Patient 1 had had a “Bad interaction.” OT 1 stated Patient 1 tried to get up, and it wasn’t safe. He stated he directed Patient 1 not to move, and they had gone “Back and forth” on this. OT 1 stated Patient 1 thought he had been “Too directive” and “Harsh” with him. OT 1 stated he had told Patient 1 “Don’t move. Don’t move” as he had been sitting on the edge of the bed. OT 1 stated they “Butted” heads and he told Patient 1 to “Stop” as he tried to get up. OT 1 stated Patient 1 had tried to explain to him that he gets himself up like that “All the time.” OT 1 denied raising his voice and stated he respected patient rights to make their own choices, but when it comes to safety he was “Not going to subscribe to that.” Record review of the document “SN OASIS Start of Care” dated 12/2/22025 showed Patient 2 was alert, oriented, cognitively intact and had no behaviors. Diagnoses included “Post-op anterior cervical diskectomy.” (diskectomy: removal of a damaged or herniated disc to relieve pressure on the spinal cord) Record review of the document “Patient Information” dated 11/10/2025 showed Patient 2 was to be evaluated for Occupational Therapy services and to receive a visit once per week for six weeks. Record review of the document “Home Health” showed OT 1 visited Patient 2 on 12/18/2025. During an interview at 10:35 a.m. on 12/30/2025 Patient 2 stated the visit on 12/18/2025 was the first visit for her spinal cord injury. Patient 2 stated OT 1 did not allow her to finish her sentences. She expressed concern he did not fully understand her symptoms, and she wanted to make sure he understood so the appropriate treatment could be put into place. Patient 2 asked OT 1 for assistance with certain exercises. OT 1 responded “You need to do it yourself.” He told her she needed to learn how to “Touch” herself and stated, “I could rub on you.” Patient 2 stated she felt “Ashamed” for asking for help as well as “Disregarded” and “Disrespected in my home.” Patient 2 stated she was homebound and needed assistance leaving her apartment. OT 1 reported to Patient 2 he wanted to “Wait several months” before assessing her for mobility devices. Patient 2 stated she started to cry as OT 1 reported he was not going to do any exercises and would “Leave it up to Physical Therapy.” Patient 2 stated, as OT 1 left her apartment he reported she might “Want to request someone else. We don’t get along.” During an interview on 1/5/2026 at 2:43 p.m., OT 1 stated during the visit on 12/18/2025 he initially reviewed Patient 2’s symptoms and then the dynamic in the room changed. Patient 2 reported to him she felt as if he were “Dismissive of her symptoms.” She stated she had some tightness in her clavicle area and asked for treatment assistance. OT 1 stated he told Patient 2 he would teach her how to “Do it herself.” He stated Patient 2 took offense to that statement and reported she was asking for help and he was dismissive of her. He denied raising his voice. OT 1 stated he tried to discuss the concerns but then things “Spiraled.” He then left the apartment. He stated he tried to explain himself, but Patient 2 was “Not having it.” During an interview at 1:57 p.m. on 12/30/2025, Social Worker 1 (SW 1) stated Patient 2 had sent her an email regarding the incident and she then sent the information to her supervisor. SW 1 stated she had no reason not to believe Patient 2. During an interview on 1/15/2026 at 2:40 p.m. the Agency’s Administrator (ADM) stated, when a patient reports a negative interaction with staff the first thing they do is gather the information and talk to the patient. The ADM stated she then talks with the clinician. If the patient requests a different staff person to provide the care, they make the change. In regard to the incident with Patient 1, the ADM stated her investigation showed Patient 1 “Perceived it” as yelling when in fact, it wasn’t. The ADM stated OT 1 was counseled on how to speak in a professional manner. The ADM stated the incident with Patient 2 was not sexually inappropriate and the investigation found OT 1 was just “Concerned about the patient.” The ADM stated the “Words from the patient were the words from the patient.” and OT 1 “Denied” the allegation. OT 1 was again coached on speaking to patients in a professional manner.”