Other·July 1, 2021

Title 42, F600 Free from Abuse and Neglect 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. Section 483.12(a) The facility must- Section 483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion 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. The following reflects the findings of the California Department of Public Health during an investigation of facility reported incident # CA00685726. The inspection was limited to the specific facility reported incident and does not represent the findings of a full inspection of the facility. The Department determined that the facility failed to ensure one resident (Resident 1) was free from physical abuse when a resident (Resident 2) with known aggressive behaviors walked over to Resident 1, grabbed for his arm, and scratched him. This failure resulted in two skin tears on Resident 1's arm, which required treatment, and increased the risk of Resident 1 experiencing a decline in his emotional wellbeing. Findings: Review of an Admission Record indicated Resident 1 was admitted to the facility in December 2019 with diagnoses, which included dementia with behavioral disturbance (cognitive decline with behaviors negatively affecting self and/or others). Resident 2's Admission Record indicated she was admitted to the facility in August 2018, with diagnoses which included dementia with behavioral disturbance, persistent mood disorder (an emotional state that is distorted or inconsistent with circumstances), anxiety disorder, and major depressive disorder. An Minimum Data Set (an assessment tool) dated 3/20/20, indicated Resident 2 required supervision, defined as "oversight, encouragement or cueing," when walking with a walker. Review of Resident 2's medical record revealed the following: A care plan for physically combative behavior, created on 1/22/20, indicated Resident 2 had a "HX [history] of Recent Episodes of Being Physically/Combative Abusive Such As: Striking Out, Grabbing at staff..." The care plan's long-term goal indicated Resident 2 would not harm herself or others. The care plan had approaches, which included, "Ensure distance in seating other residents around [Resident 2]...Observe whether the behavior endangers the resident and/or others. Intervene if necessary: Removing others from the surrounding Area...Remove resident from group activities when behavior is unacceptable..." A physician order, dated 1/22/20, indicated, "Monitor Episodes of Mood Disorder with behavioral issues: hitting, pinching, scratching...Every Shift..." A physician order, dated 3/24/20, indicated, "Merry Walker [a walker/chair combination ambulation device]...to aide in safe and independent mobility." A nursing progress note, dated 4/21/20, at 12:46 p.m., indicated, "At approx. [approximately] 1000 [10 a.m.], [Resident 2] was walking in hallway in merry walker when she approached another resident [Resident 1] and grabbed his arm in attempt to scratch...[Resident 2] has been physically aggressive with staff with behaiovrs (sic) [behaviors] of hitting, pinching, scratching and cursing...[Resident 2] continues to be aggressive." A document titled, "Behavior Monitoring Administration History," for April 2020, indicated nurses documented the number of episodes Resident 2 had behavioral issues of hitting, pinching, or scratching per shift. The record indicated Resident 2 had 38 episodes between 4/1/20 to 4/21/20, and 22 episodes from 4/22/20 to 4/30/20. Review of Resident 1's medical record revealed the following: A nursing note dated 4/21/20, at 12:44 p.m., indicated, "At apprx 1000, [Resident 1] was sitting in wheelchair in middle of hallway when another resident [Resident 2] who was agitated, walked past him and grabbed his arm. [Resident 2] was attempting to scratch [Resident 1]...[Resident 1] sustained 2 skin tears to left forearm due to incident. PA [Physician Assistant] notified, cleanse w/ [with] NS [normal saline], pat dry and apply steri strips. Change prn [as needed]..." During an interview with Licensed Nurse (LN) 1 on 5/21/21, at 2:10 p.m., LN 1 stated Resident 2 had a history of being aggressive towards staff and residents. LN 1 stated Resident 2 used to walk around the facility in her merry walker and staff would try to keep her away from other residents. During an interview with LN 2 on 5/21/21, at 2:35 p.m., LN 2 stated she was the nurse on duty who responded to the altercation between Resident 1 and Resident 2 on 4/21/20, and stated she remembered Resident 1 got skin tears from the altercation. LN 2 stated Resident 2 wandered around independently throughout the facility and moved fast. LN 2 stated "[Resident 2] would lock eyes on someone and would go after them to try to hurt them." LN 2 stated the staff tried to monitor her and divert her attention away from others to prevent her from hurting other residents. Review of a facility policy and procedure titled, "Preventing Resident Abuse," dated 1/11, indicated, "Our facility will not condone any form of resident abuse...The facility's goal is to achieve and maintain abuse-free environment."