Other·December 7, 2023

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported Incident (FRI): CA00825435. Survey Event ID: 2TYU11 Representing the California Department of Public Health: HFEN #45938. State Citation B was written. CFR 483.12 Freedom from Abuse, Neglect, and Exploitation The Patient has the right to be free from abuse, neglect, misappropriation of Patient 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. 483.12(a) The facility must- 483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; CCR 72527 (a)(10)- Patients' 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. On 2/7/23 at 10:20 a.m., an unannounced visit was conducted at the facility to investigate residents right to be free from abuse (verbal, physical, and psychological abuse). Patient 1 was hit by Patient 2 on the right side of the face, in the same spot two times, and Patient 2 threatened Patient 1 and cursed at her. This resulted in: 1) Patient 1 experiencing fear, not wanting to leave her room to participate in activities or dine in the dining room from 2/7/23 to 2/9/23, and 2) Pain and redness to the right side of her face with a pain rating (a way to measure pain so providers can help plan how best to manage the pain) of 8 out of 10 (eight and above is severe pain) that required Oxycodone (an analgesic drug acting to relieve pain) used to treat moderate to severe pain. The facility failed to ensure Patient 1 was free from verbal, physical, and psychological abuse. During a review of Patient 1's "Admission Record" (AR), undated, indicated Patient 1 had a diagnosis of Anxiety (worry and nervousness) Disorder, Unspecified. During a review of Patient 1's Minimum Data Set (MDS) assessment (tool used to identify a patient's mental and physical functioning) dated 10/13/23, the document indicated Patient 1 required extensive assistance of one person with bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Patient 1 required limited assistance with locomotion on and off the unit and eating. During a concurrent observation and interview on 2/9/23, at 1:55 p.m., Patient 1 was lying in bed. Patient 1's face was red, and her cheeks were patchy. Patient 1 had more red patchy areas on the right side of her face than the left side. Patient 1 stated she had a history of her face turning red and developing a rash when she was stressed. Patient 1 stated Patient 2 used to be her roommate. Patient 1 stated on 2/6/23, Patient 2 was leaning over her while she was lying in bed and was screaming and cursing at her then hit her with a closed fist on the right side of her face two times. Patient 1 stated Patient 2 threatened her as she was leaving the room, stating "Don't worry [Patient 1] I'm coming to get you and I will get you". Patient 1 stated she had a diagnosis of anxiety disorder. Patient 1 stated she was hysterical and had a panic attack (a sudden feeling of acute and disabling anxiety) after being hit by Patient 2. Patient 1 stated she had severe pain to her face and a sore eye after being hit and was given medication. Patient 1 stated prior to the altercation with Patient 2 she used to eat meals in the dining room two times a week and attended activities in the dining room. Patient 1 stated she could not go to the dining room to eat or for activities after being hit by Patient 2 because she was "too afraid and anxious" she would see Patient 2 there. Patient 1 stated since being hit by Patient 2 on [2/6/23], she would become startled when the door to her room shut too hard and when the lid to the clothing hamper in her room was closed. During an interview on 2/9/23, at 2:55 p.m., Patient 2 stated she hit and slapped Patient 1 once or twice in the face on [2/6/23]. During an interview on 2/9/23, at 2:57 p.m., the Activities Assistant (AA) stated he kept track of what residents in the facility were having meals in the dining room. The AA stated prior to the altercation on 2/6/23, Patient 1 normally ate in the dining room. The AA stated Patient 1 had not been to the dining room since 2/6/23 and did not leave her room since the altercation. During an interview on 2/9/23, at 3:16 p.m., the Activities Director (AD) stated she was familiar with Patient 1. The AD stated Patient 1, prior to the altercation on 2/6/23, participated in getting her nails done, movie socials, coffee socials and liked to be in the front lobby area of the facility. The AD stated Patient 1 liked to have lunch in the dining area. The AD stated Patient 1 was leaving her room prior to the altercation with Patient 2. The AD stated she had not seen Patient 1 leave her room since the altercation with Patient 2 on 2/6/23. During a concurrent observation and interview on 2/9/23, at 3:57 p.m., with Patient 1 and the AD, in Patient 1's room, Patient 1 was lying in bed. Patient 1 stated she wanted to go to the dining room for meals but was fearful and did not want to see Patient 2. The AD stated Patient 1 was fearful and did not want to see Patient 2. During a concurrent observation and interview on 2/10/23, at 10:15 a.m., in Patient 2's room, Patient 2 was sitting in her bed. Patient 2 stated she did not do what was right with Patient 1. Patient 2 stated what was right would be "knocking her out". During an observation on 2/10/23, at 10:19 a.m., in the dining room, there were 12 residents having coffee. Patient 1 was not in attendance in the dining room. During an interview on 2/10/23, at 10:48 a.m., Social Services Director (SSD) 1 stated Patient 1 was scared to be out of her room in the facility to do activities if Patient 2 was there. SSD 1 stated Patient 1 could hear Patient 2's voice while in her room and became scared Patient 2 would come in her room. SSD 1 stated Patient 1 ate meals in the dining room two to three times a week for lunch or dinner prior to the altercation with Patient 2. SSD 1 stated Patient 1 participated in activities two to three times a week prior to the altercation with Patient 2. SSD 1 stated Patient 1 had not been leaving her room since the altercation on 2/6/23 with Patient 2. During an interview on 2/14/23, at 10:00 a.m., Certified Nursing Assistant (CNA) 1 stated he was working on 2/6/23 when Patient 1 and Patient 2 had an altercation. CNA 1 stated, he was in another patient's room when he heard shouting followed by a smack through the wall. CNA 1 stated he went to Patient 1 and Patient 2's room where he saw Patient 2 shouting and cursing at Patient 1. CNA 1 stated Patient 1 was upset and irritated. During an interview on 3/15/23, at 10:34 a.m., the Certified Dietary Manager (CDM) stated Patient 1 was not dining in the dining room for any meals. During an interview on 3/15/23, at 11:07 a.m. the Restorative Nursing Assistant (RNA) stated she was familiar with Patient 1. The RNA stated Patient 1 was coming to the dining room twice a week prior to the altercation with Patient 2. The RNA stated after the altercation with Patient 2, Patient 1 did not come to the dining room to eat. The RNA stated after the altercation, "there were several days that week she didn't come out of her room at all". The RNA stated Patient 1 was afraid and teared up when talking about the altercation. During an interview on 3/15/23, at 1:05 p.m., the Social Services Designee (SSD) 2 stated he met with Patient 1 on 2/8/23 in Patient 1's room. SSD 2 stated Patient 1 wanted the door to her room closed but remained scared with the door closed. SSD 2 stated he could tell Patient 2 was scared based on his interactions with her while working at the facility for two to three years. SSD 2 stated Patient 1 was fidgety. SSD 2 stated prior to the altercation with Patient 2, Patient 1 would eat in the dining area two times a week and would be out of her room four days a week. SSD 2 stated after the altercation with Patient 2, he did not see Patient 1 come out of her room. SSD 2 stated it took about two weeks for Patient 1 to come out of her room for activities. During an interview on 3/15/23, at 2:06 p.m., the SSD 1 stated if a patient was abused and no longer wanted to leave their room out of fear, the patient would be experiencing psychosocial distress (an unpleasant emotional experience). SSD 1 stated Patient 1 experienced psychosocial distress for four days following the altercation with Patient 2. During an interview on 3/15/23, at 2:59 p.m., Licensed Vocational Nurse (LVN) 1 stated he was working on 2/6/23 when Patient 1 and Patient 2 had an altercation. LVN 1 stated the altercation between Patient 1 and Patient 2 happened around 10:45 p.m. LVN 1 stated he heard screaming coming from their shared room. LVN 1 stated that Patient 2 was cursing at Patient 1. LVN 1 stated Patient 2 threatened to physically harm Patient 1. LVN 1 stated Patient 1 was scared and crying. LVN 1 stated Patient 1 was shaking, stuttering and unable to speak properly. LVN 1 stated Patient 1 had redness to the right side of her face. LVN 1 stated Patient 1 required medication for pain after the altercation. LVN 1 stated Patient 1 had a pain level of 8 out of 10 and he administered her Oxycodone. During a review of Patient 1's "Progress Notes", dated 2/6/23, the document indicated, "... At [11:45 p.m.] there was a lot of shouting from the resident's room ... [Patient 2] was cussing profusely and making threats to physically hurt the Patient [Patient 1] ... [Patient 1] seemed extremely scared ... Upon skin assessment the [Patient 1] had redness to the right side of the face ... [Patient 1] also stated that [Patient 2] slapped [Patient 1] multiple times in the face ..." During a review of Patient 1's "Progress Notes", dated 2/7/23, at [2:13 p.m.] the document indicated, "... [Patient 1] reports right side of her face hurts ..." During a review of Patient 1's "Progress Notes", dated 2/8/23, at [9:32 a.m.] the document indicated, "... [Patient 1] stated she does feel scared ..." During an interview on 3/16/23, at 12:42 p.m., the AA stated he documented daily activities for residents at the facility. The AA stated Patient 1 attended a group activity outside of her room on 1/13/23, 1/17/23, 1/19/23, 1/20/23, 1/25/23, 1/26/23, 1/27/23, 1/28/23, 1/31/23, 2/1/23, and 2/2/23. The AA stated there was no record of Patient 1 participating in any activities on 2/7/23. The AA stated Patient 1 did not participate in out of the room activity on 2/8/23 and 2/9/23. The AA stated he met with Patient 1 on 2/9/23 in her room. The AA stated Patient 1 was afraid of Patient 2 and did not want to come out of the room. The AA stated Patient 1 appeared nervous, apprehensive, and depressed. During an interview on 3/17/23, at 1:55 p.m., SSD 1 stated there had been a previous altercation between Patient 2 and another patient at the facility. SSD 1 stated Patient 2's prior altercation with another patient was serious. SSD 1 stated the interventions put in place by the facility for Patient 2 were not effective. SSD 1 stated if Patient 2 had an intervention for one-on-one sitter monitoring (goal to keep residents safe through direct observation by staff at all times), or if Patient 2 had been isolated, the altercation with Patient 1 could have been avoided. SSD 1 stated the patients at the facility had the right to be free from abuse. SSD 1 stated being hit was physical abuse. During a review of the facility's Policy and Procedure (P&P) titled, "Preventing, Investigating, and Reporting Alleged Sexual and Abuse Violation", undated, the P&P indicated, "... Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish ... Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents ... Examples of verbal abuse include ... threats of harm ... saying things to frighten a Patient... Physical Abuse includes hitting, slapping ... Appropriate steps are taken to prevent recurrence of the incident ..." In violation of the above cited standards, the facility failed to ensure Patient 1 was free from verbal, physical, and psychological abuse when: 1) Patient 1 experienced fear, did not want to leave her room to participate in activities or dine in the dining room from 2/7/23 to 2/9/23, and. 2) Patient 1 experienced pain and redness to the right side of her face with a pain rating (a way to measure pain so providers can help plan how best to manage the pain) of 8 out of 10 (eight and above is severe pain) that required Oxycodone (an analgesic drug acting to relieve pain) used to treat moderate to severe pain. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1. 2