Other·September 11, 2025

REGULATION VIOLATION(S) F0600 42 CFR: § 483.12(a)(1) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22 CCR: § 72315(b) Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22 CCR: § 72527(a)(10) Patient's Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. 22 CCR: § 72527(a)(11) Patient's Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 22 CCR: §72523(a) Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 4/24/25 at 10:30 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an allegation of patient abuse which occurred on 4/10/25. Based on observations, interviews, and record review, the department determined the facility failed to protect one patient (Patient 1) from physical abuse by Patient 2, when Patient 2 struck Patient 1 on the head with a coffee cup. The facility failed to: - Prevent the attack on Patient 1 by Patient 2; - Take sufficient steps to mitigate the risk of assault on other patients by Patient 2, who had a history of aggressive behavior; - Create and implement a Policy and Procedure that would have reduced the risk of assault by patients who have a history of aggressive behavior. This failure resulted in Patient 1 being sent to the hospital Emergency Department (ED) for evaluation and treatment of a head injury. Findings: A review of Patient 1's "Admission Record," indicated Patient 1 was admitted to the facility on 3/2/24. Patient 1's medical diagnoses included Major Depressive Disorder (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and other symptoms that affect daily life) and Dementia (a progressive state of decline in mental abilities). A review of Patient 2's Minimum Data Set (MDS- a federally mandated patient assessment tool) dated 3/21/25, indicated Patient 2 had: - Medical diagnoses included which dementia, depression, and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves); - A Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the patient) score of 8 which indicated moderate cognitive (the mental process involved in obtaining, storing, and using knowledge) impairment; and, - Physical behavioral symptoms directed towards others (e.g. hitting) and verbal behavioral symptoms directed towards others (e.g. cursing at others). A review of Patient 2's medical chart indicated the following care plan entries: - During a Patient-to-Patient physical altercation on 2/28/25, Patient 2 hit another patient on top of the head with a plastic coffee mug. An intervention staff was expected to implement included: "Placed on 1:1 monitor [one-to-one monitoring, when one staff member is assigned to supervise and provide care to one patient only) for AM [morning] and PM [evening] shift and every 15 minutes for NOC [overnight shift] for 72 hours for whereabouts and episode of physical aggression...monitor for physical aggression- hitting another staff every shift, report to [physician] and Behavioral health for any worsening of behavior." - Patient 2 displayed physical aggression (violent behavior) on 3/23/25 by hitting staff on the head. Interventions staff were expected to implement included: "Monitor for physical aggression towards staff and [patients] q [every] shift...Observe [Patient 2's] whereabouts frequently...[and] Separate [patient] when he is becoming aggressive..." - Patient 2 displayed physical aggression towards another patient on 4/10/25, hit another patient on the head. A review of Patient 2's Behavioral Health services note dated 1/30/25 at 9:45 a.m., the Advanced Practice Registered Nurse (APRN, a nurse who completed advanced education and clinical experience in psychiatry who can diagnose and treat illnesses and prescribe medications) documented, "Mental Status...Impulse Control...Poor...Insight/Judgement...Poor..." A review of Patient 2's Behavioral Health services note dated 3/6/25 at 11:45 p.m., the APRN documented, "Mental Status...Impulse Control...Poor...Insight/Judgement...Poor...Involvement in Service...Document any...treatment considerations, and/or recommendations not covered by the rest of the assessment...staff should monitor [Patient 2] closely for any aggression or anger to help prevent violent behaviors..." A review of Patient 1's hospital ED document dated 4/10/25 at 10:10 a.m.., indicated, " ...Chief Complaint...Head injury...Physical Exam...There is a superficial abrasion at the apex [top of] the scalp measuring about 1-1/2 cm in length..." A review of Patient 1's progress note dated 4/10/25 at 5:34 p.m. indicated, "[Patient 1] was the victim of [Patient-to-Patient] Physical abuse and had to be sent out to the hospital for further Evaluation since he had a laceration [a deep, jagged wound] on his head." A review of Patient 2's progress note dated 4/10/25 at 5:38 p.m. indicated, "[Patient 2] had an unprovoked [patient] to [patient] physical altercation. [Patient 2] was sitting in the alcove drinking coffee and was sitting next to [Patient 1]...all of a sudden, [Patient 2] banged his empty cup on [Patient 1's] head hard enough to break it. [Patient 2] was screaming at [Patient 1] and staff immediately separated him...probed [to ask a series of questions to obtain information] [Patient 2] that there was something that happened earlier and [Patient 2] then said, 'oh that was because...[Patient 1] was trying to hold my shirt.' ...Reminded [Patient 2] that is the third incident..." During an interview on 4/25/25 at 1:45 p.m., Certified Nursing Assistant A (CNA A) acknowledged he was assigned as the floor monitor (a person who supervised patients to keep them safe and engaged while they sat in the common area) during the day shift on 4/10/25. CNA A stated he was familiar with Patient 2 because he had seen Patient 2 hit another patient in the head with a coffee cup. CNA A further stated Patient 2 "gets really aggressive really quick." CNA A stated he witnessed Patient 2 hit Patient 1 in the head without warning and broke his coffee cup on Patient 1's head when both patients were sitting close to each other at the nurse's station on 4/10/25. CNA A stated Patient 1 was bleeding from the head. CNA A stated he called Licensed Nurse B (LN B) after he had placed himself between Patient 1 and Patient 2 to separate them. During a concurrent observation and interview on 4/25/25 at 2:43 p.m., LN B stated the incident between Patient 1 and Patient 2 happened on 4/10/25 at around 9 a.m. LN B stated there was a floor monitor who helped to supervise Patient 2 because he was previously involved in a similar incident, where he broke his coffee cup on another patient's head. LN B stated after the previous incident on 2/28/25, Patient 2 was placed on 1:1 monitoring, then every 15-minute checks, and then he was assigned a monitor to look after him. LN B stated the floor monitor had reported to her that Patient 2 moved so quickly that he was unable to get to the patients to prevent the incident. LN B stated she applied gauze (a thin fabric typically applied to wounds to absorb fluid and provide protection to the wound) to Patient 1's head because he got a scrape that was bleeding "profusely." LN B stated she called and received orders from Patient 1's physician to transfer him to the ED for evaluation. During a concurrent observation of Patient 2 in the facility's Memory Care Unit (an area of the facility provides care to patients with Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and dementia) and interview on 4/25/25 at 3:05 p.m., Patient 2 was observed seated with patients to his left and right side. Patient 2 then independently walked toward a Surveyor without the use of an assistive device (a device used to assist a person to walk or move). Patient 2 was asked if he had hurt another patient using his coffee cup. Patient 2 stated, "Yes, I did [because] he was ' pawing' the front of my shirt." During an interview on 4/28/25 at 1:52 p.m., CNA C acknowledged CNA A had been the floor monitor on 4/10/25 during the day shift. CNA C reported that CNA A had returned Patient 1 to his room because he was annoying other patients. CNA C further stated there were about 10 or 11 patients CNA A monitored in the common area on the morning of 4/10/25. CNA C stated at around 9 a.m., Patient 1 came out of his room and sat beside Patient 2 and started watching television. CNA C stated he was walking toward Patient 1 to get his coffee cup when Patient 2 suddenly and without any provocation, hit Patient 1 on the head with a plastic coffee cup. CNA C compared the sound of the impact from the coffee cup to somebody using a hammer. CNA C stated the impact was so hard the coffee cup broke into pieces. CNA C stated he got a towel and placed it on Patient 1's head while CNA A held Patient 2 back from Patient 1 because he was still cursing Patient 1. CNA C stated LN B assessed Patient 1 and performed first aid. CNA C stated Patient 1 had a medium amount of blood on his head. During an interview on 4/30/25 at 1:55 p.m., the Director of Nursing (DON) stated she had investigated the incident between Patient 1 and Patient 2. The DON stated she spoke to LN B, CNA A, and CNA C. The DON stated CNA A and CNA C both witnessed the incident and reported to her Patient 2 struck Patient 1 on the head. The DON stated one of the CNAs described the impact on Patient 1's head was hard. The DON stated Patient 1 sustained a scrape on his head. A review of a facility policy and procedure titled, "Abuse Prevention and Management," dated 2022 indicated, "The facility does not condone any form of [patient] abuse...and/or mistreatment. The facility develops policies, procedures, training programs and...prevention systems ...Abuse is defined as the willful, deliberate infliction of injury...Prevention...The Facility maintains adequate staffing on all shifts to ensure that each resident's needs are reasonably met...The Facility identifies, corrects, and intervenes in situations in which abuse...is more likely to occur..." The department determined the facility failed to protect Patient 1 from physical abuse by Patient 2, when Patient 2 struck Patient 1 on the head with a coffee cup. The facility failed to: - Prevent the attack on Patient 1 by Patient 2; - Take sufficient steps to mitigate the risk of assault on other patients by Patient 2, who had a history of aggressive behavior; - Create and implement a Policy and Procedure that would have reduced the risk of assault by patients who have a history of aggressive behavior. This failure resulted in Patient 1 being sent to the hospital ED for evaluation and treatment of a head injury. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.