Health inspection·August 8, 2024

F600 Free from Abuse and Neglect Code of Federal Regulations, Title 42, Section 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. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; California Code of Regulations, Title 22, Section 72527. 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. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. California Code of Regulations, Title 22, Section 72311. Nursing Service--General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 72315. 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. California Code of Regulations, Title 22, Section 72523. 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 7/10/24 at 10:00 a.m., an unannounced visit was conducted at the facility to investigate facility reported incidents regarding Patient 2's fall when Patient 1 pulled his walker, and when Patient 3 punched Patient 4 on the face during an altercation. As a result of the investigation, the Department determined that the facility failed to protect Patient 2 and Patient 4 from abuse which resulted in Patient 2 sustaining a right intertrochanteric fracture (broken hip bone) and underwent hip arthroplasty (a surgery to replace the broken hip bone with an artificial implant) and Patient 4 had the potential to experience physical injury and emotional distress. 1.A review of Patient 1's admission record indicated he was admitted to the facility summer of 2024 with multiple diagnoses that included Dementia with agitation (impaired ability to remember, think, or make decisions). A review of Patient 1's Minimum Data Set (MDS, an assessment tool), dated 6/20/24, indicated, he had severe cognitive impairment. His behavior assessment section indicated he exhibited Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred 1 to 3 days. A review of Patient 1's care plan indicated, "[Patient 1] has potential to demonstrate physical behaviors r/t [related to] Anger, Dementia, History of harm to others...Date Initiated: 06/21/2024...will not harm self or others...Interventions included...Monitor/document report to MD [Medical Doctor] of danger to self and others...When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress..." A review of Patient 2's admission record indicated he was admitted to the facility spring of 2024 with multiple diagnoses that included Alzheimer's Disease (a brain disorder that affects memory, thinking, and behavior). A review of Patient 2's MDS dated 6/6/24, indicated, he had severe cognitive impairment. His functional status indicated Resident 2 had no limitation in range of motion on both upper and lower extremities. His MDS Significant Change in Status Assessment (post fall) dated 7/8/24, indicated he had developed a limitation in range of motion on his lower extremity. A review of Patient 2's Progress notes dated 6/29/2024, indicated, "While trying to enter the facility from the smoking area, pt [patient, Patient 1] and [Patient 2] were having a verbal disagreement then pt was aggressive towards [Patient 2]. pt pulled [Patient 2's] walker and caused him to fall on his back. [Patient 2] has skin tear on right elbow and pain on hip..." A review of Patient 2's Nurse's notes dated 6/29/2024, indicated, "[name] radiology dept [department] could not give a eta [estimated time of arrival] when the x-rays will be done as no tech has been assigned at this time. Will transport to [name of hospital]..." A review of Patient 2's Nurse's notes dated 6/30/2024, indicated, "[Hospital's name] called for an update resident admitted with rt [right] femur fx [fracture]. A review of Patient 2's Physician History and Physical dated, 7/5/2024 indicated, "Patient lives at a facility apparently per staff report patient had altercation with another resident took the patient's walker and pushed into the ground patient landed on his back did not strike his head. In the ED [ emergency department] x-rays revealing right intertrochanteric fracture underwent R hip arthroplasty on 7/1/24..." During a concurrent observation and interview on 7/10/24 at 12:36 p.m., Patient 2 was sitting on his wheelchair, eating lunch by the nurse's station. He stated he could not remember the incident and he could not remember why he was admitted to the hospital. He stated, he should go back to bed because his hip was hurting. During a concurrent observation and interview on 7/10/24 at 12:40 p.m., the Certified Nursing Assistant (CNA) 1 stated Patient 1 was recently transferred to the behavior room where residents were monitored every 15 minutes. He stated, Patient 1 was in station 2 as he liked to walk around. CNA 1 was observed going to station 2 to look for Patient 1. Patient 1 was then seen coming in the door in station 2 from the backyard alone. CNA 1 pointed to where Patient 1 was and proceeded to going back to the behavior room. Patient 1 walked to his room and talked about his wife but at times was unable to maintain meaningful conversation. Patient 1 stated he could not remember the incident. During an interview on 7/10/24 at 1:28 p.m., the Licensed Nurse (LN) 1 stated, she was at the nurses' station when she heard screaming and an argument between Patient 1 and Patient 2. Patient 2 was in his room and Patient 1 was coming in the door from the smoking patio. Patient 1 was standing in front of Patient 2 when Patient 1 pulled Patient 2's walker. Patient 1 picked up Patient 2's walker and was about to hit him on his head and by that time, LN 1 stated, she ran towards them and stopped him. Patient 2 lost balance and fell. LN 1 stated, Patient 2 was on the floor, bleeding from right elbow and he was saying his leg hurt. LN 1 stated Patient 1 had behaviors, sometimes he could walk around quietly then suddenly if something upsets him, he will punch you. She further stated, Patient 1 gets aggressive at times; he would punch without saying anything. During a telephone interview on 7/10/24 at 3:57 p.m., the LN 2 stated, Patient 2 was standing on the doorway of his room when Patient 1 pushed the walker into him causing him to fall. LN 2 stated, she did not think he was trying to take Patient 2's walker. She stated, Patient 1 was upset, and he pushed Patient 2. LN 2 stated, it was just that one push and Patient 2 fell and by that time the staff were able to separate the patients. The LN 2 further stated, she has not seen Patient 1 being physically aggressive, but his son informed them that he can be physically aggressive. She stated, they monitor both patients for behaviors that they noticed during the shift. She stated, we keep an eye on everyone not just these two residents. During a telephone interview on 7/12/24 at 1:09 p.m., the Director of Nursing (DON) stated, Patient 1 and Patient 2 were having a verbal disagreement in the hallway when Patient 1 pulled Patient 2's walker away from him that caused Patient 2's fall and he had a broken femur where he needed surgery for the fracture. The DON stated Patient 1 had behaviors and he had a care plan for the behavior. She also stated, Patient 1 had a monitoring for aggression but was not on every 15 minutes monitoring. The DON further stated, "we try to monitor them [patients] closely but sometimes it [altercations] can't be avoided." She stated, she expected the residents to be monitored closely to avoid these altercations from happening and if there was a care plan, she expected the staff to follow the care plan. 2. A review of Patient 3's admission record indicated, he was admitted to the facility winter of 2023 with multiple diagnoses that included Dementia, unspecified severity, without behavioral disturbance, mood disturbance and anxiety. His MDS dated 6/6/24 indicated he had moderate cognitive impairment. A review of Patient 4's admission record indicated he was admitted to the facility summer of 2024 with multiple diagnoses that included Dementia, unspecified severity, with other behavioral disturbance. His MDS dated 6/25/24 indicated he had severe cognitive impairment. His behavior assessment indicated he exhibited both Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) that occurred 4 to 6 days. A review of Patient 4's care plan indicated the following: "[Patient 4] has potential to demonstrate verbally aggressive behaviors r/t Dementia...Date Initiated: 04/30/2024...[Resident 4] will not harm self or others through the review date interventions included: Monitor and Document observed behavior and attempted interventions in chart. When [Patient 4] becomes agitated: Intervene before agitation escalates; Guide away from source of distress..." "[Patient 4] has potential to demonstrate physical behaviors r/t [related to] Dementia...Date Initiated: 04/30/2024...[Patient 4] will not harm self or others through the review date. Date Initiated: 04/30/2024, interventions included: When [Resident 4] becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation. A review of Patient 4's Nurse's notes dated 7/9/24, indicated, "Patient had a Peer to peer physical alteration [sic] with roommate. Staff heard yelling coming from the resident's room "Get out of here" and another "No you get out of here." When the staff arrived to the room, they found the resident and roommate in front of each other and both had their hands up in the air toward each other..." During a concurrent observation and interview on 7/10/24 at 12:11 p.m., Patient 4 was sleeping on his bed when a CNA came in to wake him up to ask him if he wanted to eat lunch. Patient 4 woke up and stated he wanted to eat lunch. Patient 4 then sat on his bed. He had a beard and mustache. When asked about the incident with his previous roommate, he stated, "He hit me" and he pointed on the right side of his face. He stated he could not remember the reason, but "he punched me, I don't remember why...he's not here in the room now..." During a concurrent observation and interview on 7/10/24 at 12:30 p.m., Patient 3 was standing by his bed. Patient 3 stated, he was trying to open the cupboard and his previous roommate said it was his. Patient 3 stated, "I told him it's mine, he swore at me, and he said f**** you...I punched him on the face...Yeah, I hit him on the right side of his face...He said f*** you...I'm telling you that the clothes is mine. So I, told him the clothes is mine...I punched him right on his face...He had a beard...His face is scary. Resident 3 further stated, "he was aggressive to me, he told me this is not yours; this is mine (referring to his clothes)..." During an interview on 7/10/24 at 1:41 p.m., the LN 3 stated the Director of Staff Development (DSD) was the one who heard the screaming and saw both patients in the room with both patient's arms up in front of each other looking like it's a striking pose. The LN stated, Patient 3 stated Patient 4 told him to get out of his room and that was when he punched Resident 4 on his face. During an interview on 7/10/24 at 2:00 p.m., the DSD stated she was in the hallway talking to one of the patients when she heard loud shouting, "get out of here" and, the other patient was saying "no, you get out of here". The DSD then ran into the room and both patients were in the position trying to hit each other, there was a space in between them, and she stood in front of them. The DSD stated she told them to stop but they continued to try to hit each other, she then shouted for help. The DSD further stated, Patient 4 told her Patient 3 hit him but could not point exactly where he was hit. During a telephone interview on 7/12/24 at 1:09 p.m., the DON stated, both patients had behaviors. Patient 3 was territorial and aggressive and the same thing with Patient 4 who also had verbal aggression. The incident was not witnessed as it was after they heard the commotion, then they tried to stop the incident, but nobody witnessed how it started. The DON further stated, she expected the staff to monitor residents closely to avoid these altercations from happening. If there was a care plan she expected the staff to follow it. A review of Facility policy titled, "Resident-to-Resident Altercations", revised September 2022, indicated, "1. Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents..." A review of Facility policy titled, "Resident Rights", revised February 2021, indicated, "1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect..." A review of Facility policy titled, "Abuse Prevention Program", revised August 2006, "Our residents have the right to be free from abuse...Our facility is committed to protecting our residents from abuse by anyone including...other residents..." Therefore, the facility failed to protect Patient 2 and Patient 4 from abuse when Patient 1 pulled Patient 2's walker and sustained a right intertrochanteric fracture and underwent hip arthroplasty and Patient 3 punched Patient 4 on the face during an altercation and had the potential to experience physical injury and emotional distress. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for Patient 2 and Patient 4.