Inspector’s narrative
What the inspector wrote
Licensing Program Analyst (LPA) Ashley Smith initiated a Case Management-Incident visit at 11:40AM to conclude an investigation initiated during a previous Case Management visit conducted on 2/16/2021. In attendance included Tri-Counties Regional Center (TCRC) Quality Assurance Specialist Freddie Garcia. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted via Go-To Meeting with Administrator Froilan Montes and Program Manager Monique Lopez.
On 2/16/2021, the facility submitted an Unusual Incident Report, alleging that on 2/7/2021, Staff #1 (S1) reported that they witnessed Staff #2 (S2) physically abuse Resident #1 (R1). It was alleged that R1 had a bowel movement, and S2 assisted S1 with changing R1. While S2 was assisting R1, R1 became aggressive towards S2, to which S2 allegedly pushed R1 into the hallway restroom. While attempting to change R1, S1 alleged that S2 punched R1 in R1’s back. Facility management was notified of this incident on 2/14/2021. To investigate, the LPA reviewed documentation and conducted interviews on the following dates: 2/16/2021 at 2pm; 2/18/2021 at 1:28pm, 2pm, and 2:39pm; 2/19/2021 at 10:59pm; 2/22/2021 at 10:04am and 11:40am; 2/24/2021 at 2:30pm and 3:27pm; 3/2/2021 at 2:26pm; 3/7/2021 at 9:45am and 10:26am; 3/12/2021 at 11:35am, 1pm, and 3:55pm; and, 3/15/2021 at 11:40am.
Interviews revealed varied information as to what transpired during the incident. S1 and S2 were the only staff present during the incident, and R1 was unable to provide details due to cognitive limitations. It was confirmed that during the night shift (10pm-6am) on 2/7/2021, S2 was the designated 1:1 staff for Resident #2 (R2), and S1 was responsible for the other residents. At approximately 1am on 2/8/2021, S2 allegedly left R2’s room to use the restroom, and S2 initially noticed that R1 was pacing through the hallways with feces in their hands. Details varied amongst S1 and S2 as to how R1 was led to the bathroom to get cleaned up; S1 alleged that S2 pushed R1 into the bathroom, yet S2 claimed that they guided R1 in the bathroom by pulling R1 by their clothing. S2 claimed that they used this method due to the feces observed in R1’s hands.
Interviews with staff whom work alongside S1 and S2 denied claims of observing either staff acting inappropriately with any facility resident, including R1 or R2. Interviews confirmed that in general, residents appeared comfortable working with staff and had never vocalized or disclosed being mistreated or abused.
Based on the investigation, there is insufficient evidence to confirm that S2 physically abused R1. S1 and S2 were the only staff present during the incident, and with conflicting accounts of what transpired, there is not enough information to substantiate the claim. However, the deficiencies lie in the staff’s failure to properly report the incident within 24 hours as required. In addition, interviews confirmed varied information as to how staff are expected to assist R1 when R1 displays behaviors of smearing feces. S2 agreed that their method of assisting R1 to the bathroom may have been inappropriate. S2's behavior of holding R1 by their clothing was in an attempt to restrict their movement and not allowing them to leave the bathroom, versus gaining voluntary compliance by way of practicing non-physical intervention methods.
Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 809-D).
Exit interview conducted. Appeal rights provided. A copy of this report was emailed for signature.
Whereas both S1 and S2 confirmed that R1 was resistant to receiving assistance, S1 claims that S2 punched R1 in the left shoulder with a closed fist when R1 displayed resistance, yet S2 claims that they were able to manage R1’s resistance, and held R1 by their clothing each time they attempted to leave the bathroom. S1 alleged that they responded to the abuse by informing S2 that they cannot hit residents. S2 claimed that S1 and S2 did not exchange words, other than S2 asking S1 to obtain clean clothes for R1. S1 alleged that as a result of S2 punching R1, S1 removed R1 from the bathroom and finished cleaning R1 up in the second bathroom. However, S2 claimed that they cleaned up R1 alone, denied that R1 was removed from the bathroom, and stated that they received minimal assistance from S1. Both S1 and S2 had varied accounts as to what transpired once R1 went to bed. S1 and S2 left the facility at approximately 6am on 2/8/2021.
As a part of protocol, Licensed Vocational Nurses (LVNs) conduct daily body checks on residents. There was an incident the morning of 2/7/2021 where R1 sat down too hard on a toilet and the toilet broke. Staff claimed R1 suffered an abrasion on the lower left side of R1's back. Records review confirmed that a body check was done after the incident and the abrasion was noted on the body check form. The alleged abuse took place several hours later, at approximately 1am on 2/8/2021. As a result of being hit by S2, S1 claimed that they observed a bruise on R1's back. The body check completed on 2/8/2021 documents a mark observed on the lower left side of R1's back; however, there is insufficient evidence to verify if R1 sustained additional bruising from the alleged hit from S2 or if the observed abrasion was from the toileting incident from earlier in the day.
Interviews and documentation confirmed that S1 disclosed the alleged abuse to another staff member on 2/14/2021, to which that person informed facility management on 2/14/2021. At that point, a complete body check was conducted on R1 and no injuries were noted. On approximately 2/17/2021, both S1 and S2 wrote statements regarding the incident. S2 was placed on administrative leave, pending a full investigation. Ultimately, S2 denied all claims of physical abuse, but confirmed that the technique of pulling R1 by their clothing was not a technique taught by facility management or any other training protocol. Additional staff revealed varied responses as to how staff assist R1 when R1 has feces in their hand, which included holding R1 by their wrists, verbally redirecting R1 or guiding R1 by placing hands on R1’s shoulders.
A review of R1’s initial Behavioral Support Plan, dated 9/3/2019, notes that staff are instructed to respond to R1's behavior of smearing feces in the following way(s):
Use your person or body part to block [R1] from smearing or gaining access to bodily fluids, prompt R1 to stop verbally and provide low level praise and redirect to alternative activity, keep R1 on a rigid restroom schedule, do not leave R1 unattended, address what is bothering R1, and act quickly.
