Health inspection·August 23, 2022

F600 The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00767848 and facility reported incident number CA00768215. Representing the Department, HFEN #39383. A State Citation B was written. §483.12 Freedom from Abuse, Neglect, and Exploitation 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. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 22 CCR § 72315 (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) 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. On 1/7/22, at 9:15 a.m., an unannounced visit was conducted to investigate a complaint and facility reported incident that Resident 1 had been hit in the face with a cane by Resident 2. On 1/5/22 around 11 a.m., Resident 2 asked a staff member for permission to go into Resident 1's room to visit Resident 1. A few minutes later Resident 1 yelled he had been hit and Resident 2 was seen leaving Resident 1's room, walking with a cane. Resident 1 was in his bed with blood in his mouth. Resident 1 was sent to the hospital Emergency Department where physicians noted he was "likely" missing a tooth from the physical assault. The facility failed to protect Resident 1 from physical abuse by Resident 2 when facility staff gave permission to Resident 2 to enter Resident 1's room without supervision. This resulted in Resident 1 being hit in the face with a cane by Resident 2, causing Resident 1 painful cuts in the mouth, loss of a tooth, and psychological/emotional distress. A review of Resident 1's, "Admission Record," dated 1/7/22, indicated Resident 1 was admitted to the facility in 2019 with diagnoses of dementia (a brain disorder that affects the ability to remember, think clearly, communicate), generalized weakness, and difficulty walking. The Admission Record indicated Resident 1's primary language was non-English. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 11/11/21, indicated Resident 1 preferred a non-English language and use of a translator for communication. The MDS indicated Resident 1 required physical assistance from one person for bed mobility and transfer between surfaces, extensive assistance from one person for dressing and locomotion, and used a wheelchair for locomotion. The MDS indicated Resident 1 had highly impaired vision (appears able to track objects, but questionable identification of objects). The MDs indicated Resident 1 had verbal behaviors directed toward others (threatening, screaming, cursing). A review of Resident 2's Admission Record indicated an admission date of 12/21/21 with diagnoses of heart failure and difficulty walking. A review of Resident 2's MDS dated 12/27/21, indicated Resident 2 required limited assistance from one person for transfer between surfaces, and only needed supervision or set-up help for locomotion on the unit. The MDS indicated Resident 2 used a walker or wheelchair for locomotion. During an interview on 1/24/22 at 10:05 a.m. with CNA 1, CNA 1 stated she was familiar with Resident 1, who had a habit of yelling from his room, which was close to the nurse station. CNA 1 stated she was familiar with Resident 2, who used a wheelchair and had learned to use a cane. CNA 1 stated she had been working on the morning of 1/5/22, when Resident 2 asked her if he could visit Resident 1 in his room. CNA 1 stated she told Resident 2 he could visit Resident 1 and he entered Resident 1's room. CNA 1 stated she then heard yelling coming from Resident 1's room and noticed Resident 2 walking away from Resident 1's room. CNA 1 stated when she went into Resident 1's room, Resident 1 was bleeding from his mouth. During a telephone interview 1/11/22 at 11:12 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she had been at the nurse station by Resident 1's room on 1/5/22, when she heard Resident 1 yell, "Somebody hit me!" LVN 1 stated she looked over at Resident 1's room and saw Resident 2 walking with a cane, coming out of Resident 1's room. LVN 1 stated she asked Resident 2 what had happened as she went to Resident 1's room, and he said, "I don't know." LVN 1 stated she entered Resident 1's room and found Resident 1 in bed, bleeding from his mouth. LVN 1 stated Resident 1 was sent to acute care hospital for evaluation. A review of Resident 1's acute care hospital document titled, "Emergency Department Note," dated 1/5/22, indicated Resident 1 was seen by the physician 1/5/22, at 1:12 p.m. The Emergency Department Note indicated Resident 1 was seen for an injury to his lower jaw after he was hit by another patient with a metal cane earlier that morning. The Emergency Department Note indicated Resident 1 should be seen by a dentist, as he "most likely" had a missing tooth as a result of the injury. During an observation and interview on 1/7/22 at 9:30 a.m., with Resident 1 and a translator (Director of Rehabilitation, DOR) in Resident 1's room, Resident 1 was in bed eating breakfast. Resident 1 had a dark mark on his mouth. When Resident 1 was asked how he got the mark, he stated that someone had hit him with something made of metal a few days ago. Resident 1 stated he had painful cuts in his mouth. When Resident 1 was asked what had happened before he was hit, Resident 1 stated he had been calling for his eye drops and was suddenly hit. Resident stated it was the first time he had been hit but he lost three teeth and doesn't feel safe here anymore. During an interview on 1/24/22 at 4:20 p.m., with Resident 2, Resident 2 stated his stay at the facility was "OK," except some people screamed and yelled for "no reason at all." Resident 2 stated there was one "guy" who was irritating because he randomly yelled day and night, keeping people awake. Resident 2 denied going into any other resident's room and denied hitting anyone. In violation of the above cited standards, the facility failed to protect Resident 1 from abuse by Resident 2, including but not limited to, the failure of facility staff to give permission to Resident 2 to enter Resident 1's room without supervision. This resulted in Resident 1 being hit in the face with a cane by Resident 2, causing Resident 1 painful cuts in the mouth, loss of a tooth, and psychological/emotional distress.