Health inspection·June 1, 2023

Health and Safety Code Section 1424 (d): Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. §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. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The Department determined during the investigation of a facility reported incident, the facility failed to protect Resident 1 from physical abuse by a Certified Nursing Assistant (CNA 1) when CNA 1 threw a cordless telephone at Resident 1 and hit him in the mouth. As a result of this failure, Resident 1 sustained a bloody mouth and swollen lips. Review of Resident 1's face sheet indicated the resident was a 61-year-old male admitted to the facility on 1/17/21 with history of a stroke with left sided weakness/partial paralysis. During an interview on 11/22/22, at 1:30 p.m., with Resident 1, Resident 1 stated, on 11/21/22, CNA 1 brought a portable phone from the nursing station for the resident to use to call his wife. CNA 1 brought resident the phone and stayed in the room with the resident. After a couple of minutes, he was taking too long using the phone, CNA 1 came close to the resident to take the phone from him, but resident took the phone out of CNA 1's hand and threw it against the wall. CNA 1 came over and punched Resident 1 in the mouth and then left the room. During an interview on 11/22/22, at 2 p.m., with Licensed Nurse (LN 1), LN 1 stated, during med pass, approximately 9 a.m., heard Resident 1 scream for nurse. Upon arrival to Resident 1's room Resident 1 stated to LN 1, CNA 1 hit him in the mouth, and he wanted to call the police. LN 1 observed Resident 1 had blood in mouth and lips and lips started to swell. LN 1 immediately notified the Director of Nursing (DON). Treatment Nurse assessed and treated Resident 1, mouth was cleaned, ice applied to the swelling, and pain medication provided. During a concurrent interview and document review, on 11/22/22, at 2:10 p.m., with the DON, the facility investigation and CNA 1's signed statement were reviewed. The DON stated, CNA 1 was sent home right away following the allegation, around 9:30 a.m. The DON spoke with CNA 1 and a statement was taken. The signed statement was reviewed with the DON. The signed statement by CNA 1 indicated, Resident 1 threw the facility phone, he picked it up and threw it back towards Resident 1 where it hit the bedside table, bounced off the table, and it hit Resident 1 in the mouth. CNA 1 indicated it was an accident and he had no intention of hitting Resident 1 with the phone. The DON spoke with Resident 1 shortly after the allegation, and the resident indicated, CNA 1 punched him in the face. During an interview on 11/22/22, at 2:45 p.m., with CNA 2, CNA 2 indicated, CNA 1 approached her about switching assignments after there was a "commotion" in the room of Resident 1. CNA 1 wanted to switch assignments because he got into an argument with Resident 1. The assignment change did not happen once the facility administrator became aware of the "commotion". During a concurrent interview and document review, on 11/22/22, at 3:45 p.m., with the facility administrator (ADM 1), The document titled, "Summary of Investigation," and the signed statement from CNA 1 were reviewed. ADM 1 acknowledged being part of the investigation conducted by the DON and confirmed the signed statement by CNA 1 conveys what was communicated during the interview. ADM 1 indicated, there were no witnesses to the allegations as the curtains were drawn in Resident 1's room. Upon interview of CNA 1 by ADM 1 shortly after the incident, CNA 1 stated, he threw the phone in the direction of Resident 1 where it bounced off the bedside table, and it hit Resident 1 in the mouth. During an interview on 12/15/22, at 1:30 p.m., with the Assistant Director of Nursing (ADON), the ADON indicated, LN 1 notified her Resident 1 wanted the police called because he was hit by CNA 1. The ADON interviewed Resident 1 and Resident 1 stated, CNA 1 punched him in the mouth. The ADON stated, she did not see any bleeding in Resident 1's mouth but observed a skin tear to the resident's upper lip and the resident was very upset. During an interview on 12/15/22, at 3:40 p.m., with the Ventura Police Officer (VPO), the VPO indicated, the following results of the investigation at the facility involving Resident 1 and CNA 1. The VPO was on site at the facility within an hour of the call to the Ventura Police Department. The VPO stated, Resident 1 stated, he needed to call his wife and he requested nursing staff to help him by allowing him to use the phone at nursing station. There was a brief verbal argument and Resident 1 threw the phone across the room. Resident 1 then stated, the nursing staff came over and punched him in the mouth. The VPO observed a visible injury to the resident's lip. During an interview on 1/12/23, at 3:30 p.m., with Certified Nursing Assistant Student (CNAS 1), CNAS 1 indicated, she was at the nursing station next to Resident 1's room. CNAS 1 was just outside the nursing station. CNAS 1 indicated she saw CNA 1 at the nursing station getting the portable phone for Resident 1 to use as Resident 1's personal cell phone was not working. CNAS 1 heard a sound coming from behind closed curtains of Resident 1's bed and saw a phone hitting the floor. CNAS 1 then heard a yell for help coming from Resident 1's room. When CNAS 1 entered Resident 1's room, CNA 1 was leaving the room. CNAS 1 asked CNA 1 what was going on, but CNA mumbled something that was not understandable. Resident 1 stated to CNAS 1 that CNA 1 punched him in the mouth. CNAS 1 saw blood coming out of the Resident 1's mouth and lips were covered in blood. During the review of a handwritten, untitled document, dated 11/21/2022 and signed by CNA 1, the document indicated, "It was about 9:15 am when I came back from drinking coffee and I went to check on my patients in room 24. I approached to (Resident 1's name) and I saw the phone from the nursing station on his table, I grabbed it and started dialing his wife, (Resident 1's name) maybe was angry and wanted to hit me, I leave the phone on his table, he grabbed it and threw it at me, then I threw it back, the phone bounced on the table and hit him in the mouth, but it was never my intention to hit him with the phone. (Resident 1's name) grabbed the phone and threw it at me again and shot up on the floor. I left the room to tell the nurse what happened, (Nurse's name) told me that he was not her patient, the nurse in charge was (Charge Nurse's name), I looked for him to tell him what happened" The facility failed to protect Resident 1 from being physically abused by CNA 1 when CNA 1 threw a cordless telephone at Resident 1 and hit him in the mouth. As a result of this failure, CNA 1 hit Resident 1 with a portable phone causing injury. This failure presented a violation of Resident 1's rights, and likely to cause significant humiliation, indignity, anxiety, and emotional trauma.