Health inspection·July 17, 2024

F 610 Investigate/Prevent/Correct Alleged Violation, Section 483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. On 5/7/24 at 1 p.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an allegation of resident safety. The department determined the facility failed to ensure the safety of two residents (Resident 1 and Resident 2) after Licensed Nurse 1 witnessed Resident 1 slap Resident 2 on the face and did not separate Resident 1 and Resident 2 into different rooms. This failure led to Resident obtaining a 4.5 centimeter (cm, a unit of measure) by 3.5 cm bruise along the right cheek and jaw due to continued exposure to the alleged perpetrator. A review of Resident 1's admission record indicated admission to the facility on 8/25/20 with diagnoses which included neurocognitive disorder with Lewy Bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function) and dementia with psychotic disturbance (the mental state where someone is not sure what is real or not). A review of a Minimum Data Set (MDS, an assessment tool) dated 3/4/24 indicated Resident 1 had a severe memory problem. A review of Resident 2's admission record indicated admission to the facility on 4/16/24 with diagnoses which included dementia with other behavioral disturbance (such as agitation, depression, and psychosis). A review of a MDS dated 4/22/24 indicated Resident 2 had a moderate memory problem. A review of Resident 1's progress note written by LN 1 dated 5/2/24 at 5:41 p.m. indicated, "...[Resident 1] got up, entered roommate bed...and slapped [Resident 2] in the face...This patient's behavior escalates during evenings and nighttime. [Resident 1] has become more aggressive and combative..."" A review of Resident 2's progress note written by LN 1 dated 5/2/24 at 7:13 p.m. indicated, "[Resident 2] had confrontation with roommate who suffers from dementia. Staff intervened and redirected both residents to their beds. Advised patient not to touch other residents. WCTM [Will continue to monitor]." A review of Resident 1's progress note written by LN 2, dated 5/3/24 at 7:01 a.m., indicated, "During my morning rounds, I noticed a blue-purplish bruise on the right jawline, upper lip and lower lip. NP [Nurse Practitioner] was notified of the bruises found. Cold compress and x-ray order [sic]. Orders noted and carried out." A review of Resident 1's progress note written by LN 3, dated 5/3/24 at 12:27 p.m., indicated, "At 11:00 am on 5/3/24. Head to toe skin assessment completed by two LN and 2 CNA [Certified Nursing Assistant] assisted with repositioning resident...informed [Resident 1] that will conduct skin assessment. Resident lying in bed alert and awake with no over s/sx [signs and symptoms] of pain, no episode of restlessness or aggressive behavior, she is calm, pleasant and cooperative. Right lower jaw reddish skin discoloration (4.5 cm [centimeters, a unit of measure] x 3.5 cm) right side of face down to right jaw greenish to reddish discoloration 4.5 x 4.0 cm redness to right jaw measures 2.0 x 3.0 cm left upper lip scratched with dry blood right lower lip reddish discoloration 92.0 x 1.0) right breast dark discoloration 91.0 x 1.0 cm)...left cheek scratch (2.0 x 0.5 cm)..." A review of Resident 1's social service progress note dated 5/3/24 at 12:52 p.m. indicated, "[Resident 1] to be moved...as a plan of care after alleged Resident to Resident altercation filed on 5/3/24...Will monitor for 72 hours post room change." A review of Resident 1's NP progress note dated 5/3/24 at 1:26 p.m. indicated, "...According to nursing staff, patient had altercation with other resident...I noted large bruise on the right jaw, bruises on the upper and lower lip, and bruise on inner thigh. There is no documentation how patient got those bruises...Changes: stat x-ray of jaw; monitor the bruises for worsening; patient is moved, monitor closely." A review of Resident 1's Interdisciplinary Team (IDT) progress note dated 5/3/24 at 6:36 p.m. indicated, "[Resident] to [Resident] Altercation...Date of Incident: 5/2/24...Allegation was witnessed by [LN 1], resident 1 slapping resident 2 on the face...According to [LN 1] documentation, resident 1 got up and went to resident 2 area and slapped her on the face. [LN 1] approached the event by getting in the middle to separate both and redirect. Based on interview of the [LN 1], she stated she received the last remaining punches on her abdomen. [LN 1] was successful in redirecting resident 1 and resident 2 to their appropriate beds. In a telephone interview on 5/24/24 at 9:55 a.m., the NP stated she was notified of Resident 1 and Resident 2's altercation the morning of 5/3/24. The NP stated the LN 1 was expected to move Resident 1 to a different room to ensure another altercation did not occur. In a telephone interview on 5/22/24 at 4:53 p.m., the Nurse Supervisor (NS) confirmed she worked the evening (PM) shift on 5/2/24 was not made aware of the altercation between Resident 1 and Resident 2 by LN 1. The NS stated nurses were expected to notify nurse supervisors of abuse so staff could find a room to move one of the residents to ensure their safety. The NS stated, "I would have made sure they were both separated, and both monitored." In a telephone interview on 5/22/24 at 5:20 p.m., the LN 2 stated LN 1 had mentioned an incident between Resident 1 and Resident 2 had occurred on the evening of 5/2/24 but had not been specific as to what happened. The LN 2 stated when she rounded on Resident 1 and Resident 2, they were in the same room. The LN 2 stated she was shocked to see bruises on Resident 1's face. The LN 2 referred to Resident 1's chart, there was no documentation of what occurred to explain the bruises on Resident 1's face. The LN 2 also stated both Resident 1 and Resident 2 were confused but capable of getting out of bed by themselves and added both were not weak and could potentially cause damage to each other. In a telephone interview on 5/24/24 at 10:16 a.m., the Certified Nurse Assistant 1 (CNA 1) confirmed she was assigned to care for Resident 1. The CNA 1 denied moving either Resident 1 or Resident 2 to a different room during her shift on 5/2/24. The CNA 2 stated if a licensed nurse notified her of an altercation between resident roommates, the protocol was for the residents to be separated into different rooms to make sure they were safe while the nurses conduct the investigation. In a telephone interview on 5/24/24 at 10:27 a.m., the LN 1 stated on 5/2/24 during the PM shift she heard screaming. The LN 1 stated she and CNA 2 went to Resident 1's room and when they arrived Resident 1 was naked and hitting Resident 2. The LN 1 reported Resident 2 yelled, "That woman is trying to hit me" as she was pointing to Resident 1. The LN 1 also reported she had been kicked in the back by Resident 1 and stated CNA 2 was a witness to it. In a telephone interview on 5/24/24 at 11:04 a.m., the CNA 2 stated during his shift on 5/2/24. The CNA 2 stated he did not see any hitting or kicking from Resident 1 or Resident 2 that night. The CNA 2 verified Resident 1 nor Resident 2 were moved to another room during his shift on 5/2/24. In an interview on 6/3/24 at 2:51 p.m., the DON confirmed she was not informed by LN 1 she witnessed Resident 1 slap Resident 2 in the face. The DON stated had she been notified; she would have instructed LN 1 to collaborate with the NS to move either Resident 1 or Resident 2 to a different room. The DON stated if she had been unavailable, the LN 1 could have also notified the admissions department, the NS, and the Infection Preventionist (IP). The DON stated she expected the licensed nurse to separate residents to ensure safety and to monitor all residents involved in the abuse. The DON verified the LN 1 did not follow the facility's policy and procedure regarding abuse. A review of the facility's policy and procedure titled "Reporting Abuse" revised 1/8/14, indicated, "...The facility will ensure that the resident has the right to be free from verbal, sexual, physical, and mental abuse...Facility Staff as Mandated Reporters...If the allegation [of abuse] is regarding a resident-resident altercation, the residents will be separated immediately, pending the investigation...Responding to an Allegation... If the allegation [of abuse] is regarding a resident-resident altercation, the residents will be separated immediately, pending the investigation." Therefore, the department determined the facility failed to ensure the safety of two residents (Resident 1 and Resident 2) after Licensed Nurse 1 witnessed Resident 1 slap Resident 2 on the face and did not separate Resident 1 and Resident 2 into different rooms. This failure led to Resident obtaining a 4.5 centimeter (cm, a unit of measure) by 3.5 cm bruise along the right cheek and jaw due to continued exposure to the alleged perpetrator. This violation had a direct or immediate relationship to the health, safety, and security of residents.