Health inspection·November 15, 2023

F603 Free from Involuntary Seclusion 483.12 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; 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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (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. 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 3/16/2023 at 10:41 a.m., the California Department of Public Health (CDPH) made an unannounced visit at the facility to investigate one facility reported incident and one complaint regarding a resident-to-resident altercation. On 3/7/2023, around 9:45 a.m., Resident 3 hit Resident 4 on the face and arms with a fist. Resident 4 was transported to the emergency department (ED) and treated for facial swelling and a closed head injury. Police took Resident 3 into police custody. Based on interview and record review, the facility failed to protect 2 of 5 sampled residents (Resident 3 and Resident 4) and ensure they were free from physical abuse. The facility failed to: 1. Prevent Resident 3 from striking Resident 4, resulting in Resident 4's hospitalization and Resident 3's arrest; 2. Adequately assess and consider appropriately Resident 3's history of combative behavior; and, 3. Ensure the Facility's policy and the facility assessment was followed for residents with a combative behavior history. As a result, Resident 4 was transferred to the ER for facial injuries, a closed head injury, and psychological trauma evidenced by fear of returning to the facility. A review of Resident 4's, "Admission Record," dated 3/7/2023, indicated Resident 4 was a 73-year-old male admitted to the facility on 2/18/2023 with the following diagnoses: malignant neoplasm of the brain steam (cancerous tumor of the lower part of brain responsible for breathing and heartbeat), and quadriplegia C1-C4 incomplete (paralysis of all four limbs). A review of Resident 4's Minimum Data Set (MDS, an assessment tool), dated 2/20/2023, indicated Resident 4 had intact cognition. A review of Resident 3's, "Admission Record," dated 3/16/2023, indicated Resident 3 was a 75-year-old male admitted to the facility on 2/17/2023 with the following diagnoses: unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), and schizophrenia (a mental illness that affects how a person thinks, feels, and behaves). A review of Resident 3's MDS, dated 2/20/2023, indicated Resident 3 had mild cognitive impairment. 1. During a telephone interview with Resident 4 on 03/16/2023, at 1:05 p.m., Resident 4 stated he recalled Resident 3 hitting him on the head but could not remember too much after he was repeatedly hit on the head with Resident 3's hand. Resident 4 stated he was sent to the hospital after Resident 3 hit him. Resident 4 further stated he did not feel safe to return to the facility. A review of Resident 4's Interdisciplinary Team (IDT) note, dated 3/7/2023, at 5:09 p.m., indicated, "At approximately 0945 [3/7/2023] ... Per [Resident 4] interview roommate [Resident 3] struck him in the face with his hand and cane... staff member notified nursing staff of roommate [Resident 3] standing at res [Resident 4] bedside with cane in hand..." The note further indicated Resident 4 had blood on his face. A review of Resident 3's IDT note, dated 3/7/2023, at 4:16 pm., indicated, "At approximately 0945 this am [sic; morning] [3/7/2023] states he... struck his roommate... he used only his hands to strike roommate." The note further indicated, "environmental services... was alerted to [Resident 3] standing over roommate with his cane in hand and roommate [Resident 4's] face bleeding..." The IDT note indicated the local Sheriff's Department took Resident 3 into custody for, "Felony Elderly Abuse based upon the nature of roommates injuries." A review of an, "ED Provider Note," from General Acute Care Hospital (GACH) 1, dated 3/07/2023, indicated Resident 4 sustained the following injuries: "Upper lip contusion with some swelling, swelling around left eye with ecchymosis [a discoloration of the skin caused from bleeding under skin] of the eyelid, multiple areas of abrasion [an area damaged by scraping] and excoriation [area of scraped off skin] of the face and upper neck area." 2. During a review of a progress note titled, "PATIENT HISTORY & PHYSICAL (H&P)," dated 2/17/2023 at 10:23 p.m., the H&P indicated Resident 3 was, "... admitted in [GACH 2] on 2/12/2023 for being combative with other residents at care facility," which indicated Resident 3 had a history of aggressive behaviors. During a concurrent interview and record review with the administrator (ADM) on 3/16/2023 at 2:25 p.m., the ADM stated the facility was, "not able to care for residents with aggressive behaviors." The ADM further stated residents with a history of being combative were not appropriate for the facility and there was no capacity to care for those residents. The ADM stated if a resident has combative behaviors the facility assessment, section 1.4, would be used to determine if a resident is appropriate for the facility. A review of the "Facility Assessment Tool," dated 2/25/2022, indicated, "1.4 Admissions will only be accepted once the ability to provide the proper care is verified by the Director of Nursing (DON) and the Interdisciplinary team (IDT). Care decisions for residents that develop a condition that is not familiar will go through the same process." During an interview on 3/16/2023, at 2:05 p.m., DON stated Resident 3 was assessed at the GACH by the administrator and if he had aggressive behaviors, he would not have been admitted at the facility. The DON stated residents with a history of aggressive behaviors are not appropriate admissions for the facility. The DON further confirmed she did not assess Resident 3 at the hospital prior to his admission to the facility. During an interview on 3/16/2023 at 2:25 p.m., with the ADM, the ADM stated he visited Resident 3 at the hospital prior to admission and Resident 3, "was very appropriate the whole time." The ADM further stated residents with a history of being combative are not appropriate for admission as they are "not able to provide care" and the facility had no capacity to care for such residents. 3. During a concurrent interview and record review on 3/22/2023 at 3:57 p.m., with the DON, the DON stated Resident 3 was monitored every shift for behaviors, which were charted in the Medication Administration Record (MAR). During a review of the MAR with the DON, the DON stated Resident 3 had three episodes of agitation between 3/3/2023 and 3/4/3023. The DON confirmed prior to 3/3/2023, Resident 3 had no episodes of agitation charted. A record review of Resident 3's, "Skilled Charting 3," dated 3/4/2023 at 10:01 p.m., indicated Resident 3 had, "No changes to mood or behavior." The DON confirmed there was no documentation in the chart to describe Resident 3's agitation that occurred on 3/3/2023 and 3/4/2023. The DON confirmed there was nothing in Resident 3's "Skilled Charting 3" to indicate what behaviors were noted in the MAR. The DON confirmed if staff were to complete a review of the resident's medical records no one could interpret what agitation Resident 3 experienced. During a telephone interview on 3/27/2023 at 10:05 a.m., with Pharmacist (PD), the PD stated the nursing charting was incomplete and without correct documentation of behaviors of agitation, medication recommendations could not be made. During a telephone interview on 3/27/2023 at 11:30 a.m., with Medical Doctor (MD), the MD stated he was not made aware of any agitation Resident 3 experienced on 3/3/2023 or 3/4/2023. The MD stated he reviewed the nursing notes to determine if any changes in the residents occurred. The MD further stated if there was no documentation, he would not be able to make any needed referrals for adjustments of behaviors. A review of facility policy titled, "Charting and Documentation," dated July 2012, indicated, "The following information is to be documented in the resident medical record: ... d. Changes in the resident's condition..." A review of facility policy titled, "Policy Abuse and Prevention," dated December 2017, indicated, "Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual." Based on interview and record review, the facility failed to protect 2 of 5 sampled residents (Resident 3 and Resident 4) and ensure they were free from physical abuse. The facility failed to: 1. Prevent Resident 3 from striking Resident 4, resulting in Resident 4's hospitalization and Resident 3's arrest; 2. Adequately assess and consider appropriately Resident 3's history of combative behavior; and, 3. Ensure the facility's policy and the facility assessment was followed for residents with a combative behavior history. As a result, Resident 4 was transferred to the ER for facial injuries, a closed head injury, and psychological trauma evidenced by fear of returning to the facility. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 4.