Health inspection·October 3, 2024

Kit Carson Nursing and Rehabilitation Center The following reflects the findings of the California Department of Public Health during a Recertification Survey and the investigation of Facility Reported Incident (FRI) #CA00919930. Survey Event ID: TKIT11 State Citation B was written. A deficiency was written for FRI #CA00919930 at F-tag 600. 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. On 9/9/24 at 8:00 a.m., an unannounced visit was conducted at the facility to conduct a Recertification Survey and to investigate FRI #CA00919930 regarding a resident-to-resident altercation. The facility failed to provide a safe environment and the supervision needed to ensure Resident 39 was protected from physical abuse when another resident (Resident 79), who had a history of severe mental illness and violent behaviors, entered Resident 39's room, and struck him in the face multiple times resulting in Resident 39 sustaining facial bruising and redness, a cut lower lip, overall head pain, and fearfulness. A review of Resident 39's clinical record titled. "Admission Record" (a document that contained the resident's demographic information), indicated Resident 39's diagnoses included Multiple Sclerosis (a disease that blocks messages between the brain and body, causing a variety of symptoms, including muscle weakness). During a concurrent observation and interview on 9/9/23, at 11:14 a.m., with Resident 39, in his room, Resident 39 was observed to have a cut on his left lower lip, and his face was red with bruising around his eyes and nose. Resident 39's left hand and arm were observed to have contractures (permanent shortening of muscles that limit movement and causes stiffness), and his legs were unable to move. Resident 39 stated that Resident 79 came into his room and hit him in the face 15 times. Resident 39 stated if the nurses hadn't come to his room when they did, Resident 79 could have killed him. Resident 39 stated he still had pain in his head. A review of Resident 79's clinical record titled, "Admission Record", indicated Resident 79's diagnoses included schizophrenia (a serious mental health condition that affects how people think, feel and behave) and bipolar disorder (a mental illness that causes extreme mood swings). A review of Resident 79's clinical record titled, "Progress Notes", dated 4/18/24, at 6:08 a.m., by Licensed Nurse (LN) 10, indicated a loud sound was heard at Nurses' Station 1. The progress note revealed that Resident 79 attacked a licensed nurse and pushed him against the door and had both hands around the nurse's neck. A female nurse tried to help the nurse when Resident 79 slammed her on the desk and to the floor. Resident 79 kept saying, "he has a gun". A review of Resident 79's clinical record, titled "Progress Notes", dated 4/14/24, at 6:48 p.m., by the Minimum Data Set Nurse (MDS nurse - nurse who assessed and monitored the health of patients in long-term care facilities), indicated Resident 79 shouted at a Certified Nursing Assistant (CNA), pulled his hair, and hit him on the head. A review of Resident 79's clinical record titled, "Physician's Progress Notes/Psychological Evaluation", dated 5/25/24, by Medical Doctor (MD) 1, indicated Resident 79 had become more paranoid (suspiciousness, distrust, and feelings of persecution) over the past few days and his Schizophrenia and dementia (a decline in mental abilities that could affect a person's ability to perform everyday activities) was uncontrolled. A review of Resident 39's clinical record titled, "Progress Notes", dated 9/6/24, at 2:09 a.m., indicated Resident 39 was hit repeatedly on his face by Resident 79. Resident 39's face was red and bruised along the nasal bridge (top of the nose) and under the eyes, and his eyes were blood shot (red/irritated). A review of Resident 39's clinical record titled, "Progress Notes", dated 9/6/24, at 2:48 a.m., by LN 8, indicated that at around 12:58 a.m., Resident 79 was heard by staff stating, "I'm going to kill him" and went into Resident 39's room and beat him by slapping him in the face. Resident 39 stated he was hit in the face 15 times. A CNA ran over to the room and pulled Resident 79 off of Resident 39 by pulling him by the back of his pants. Resident 79 grabbed the CNA by the right arm and knocked her down. The police were called and arrived at the facility. The progress note indicated other residents in the facility were afraid. A review of Resident 79's clinical record titled, "Progress Notes", dated 9/6/24, at 2:58 a.m., indicated Resident 79 had tried to bend a LN's hand backward. Resident 79 said there were people in his room with guns. A review of Resident 79's clinical record titled, "Progress Notes", dated 9/6/24 at 8:59 a.m., by LN 1, indicated Resident 79 yelled, "she's in there and he has her". A review of Resident 79's clinical record titled "Progress Notes", dated 9/6/24, at 9:00 a.m., by LN 9, indicated Resident 79 was banging on the office doors stating there was an 18-year-old lady trapped inside the office. A review of Resident 39's clinical record titled, "Progress Notes", dated 9/6/24, at 2:34 p.m., by Social Services (SS), indicated, "Resident 39 stated, 'He was yelling in the hallway saying stuff angry and I told him Hey man calm down. He then came to my door still yelling and I told him man calm down. After I said that he came into my room all angry towards me and slammed my computer to the floor and he started to punch me. He punched me like 15 times ... I was scared for my life. It took you guys a long time to come and save me ... If they didn't stop him, he would have killed me' ... ". Resident proceeded to express, 'Look at my face I was beat up ... I could have died' ...". During an interview on 9/11/24, at 2:03 p.m., with LN 4, LN 4 stated after Resident 79 attacked Resident 39, Resident 39 was very afraid for his safety. LN 4 stated Resident 79 hit Resident 39 in the face approximately 15 times. LN 4 stated Resident 39 was a vulnerable resident who could not defend himself. LN 4 stated, Resident 39 was emotional and upset after the incident. During an interview on 9/12/24, at 8:55 a.m., with Resident 46, Resident 46 stated she did not feel safe when Resident 79 lived at the facility. During a concurrent interview and record review on 9/11/24, at 3:36 p.m., with the Administrator (ADM), the facility's Policy and Procedure (P&P) titled, "[FACILITY NAME] Abuse Prohibition Policy and Procedure", dated 2021, was reviewed. The P&P indicated, " ... Abuse is defined as the willful infliction of injury ... resulting physical harm, pain, injury, or mental anguish ... physical abuse includes hitting, slapping, pinching, kicking, etc. ....". Purpose - to ensure that [FACILITY NAME] staff are doing all that is within their control to prevent occurrences of abuse ( ... physical) ... for all patients...". The ADM stated she did not deny that Resident 39 was attacked by Resident 79, but stated it was not abuse. A review of the facility's P&P titled "Safety and Supervision of Residents", dated 4/24, indicated, " ... The care team shall target interventions to reduce individual's risks ... including adequate supervision ..." A review of the facility's P&P titled, "Resident Rights", dated 1/24, indicated, " ... Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: ... be free from abuse ..." In violation of the above cited standards, the facility failed to provide a safe environment and the supervision needed to ensure Resident 39 was protected from physical abuse when another resident (Resident 79), who had a history of severe mental illness and violent behaviors, entered Resident 39's room, and struck him in the face multiple times resulting in Resident 39 sustaining facial bruising and redness, a cut lower lip, overall head pain, and fearfulness, including but not limited to: Resident 39 sustaining facial bruising and redness, a cut lower lip, overall head pain, and fearfulness. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.