Health inspection·December 20, 2023

F600 §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; Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect Resident 1 who was known to have wandering and behaviors of taking other people's foods and on 1:1 supervision from the physical abuse by Resident 2. Resident 2 had struck Resident 1 in the face during an altercation when Resident 1 had wandered into Resident 2's room and attempted to take Resident 2's milk. This failure resulted in Resident 1 suffering a left nasal bone fracture, blunt head and facial trauma, a cerebral concussion (a type of traumatic brain injury caused by a bump, blow, or jolt to the head which may cause damage to brain cells). Findings: Review of the facility's P&P titled Abuse-Prevention, Screening, and Training Program revised 7/2018 showed in part, the facility does not condone any form of resident abuse ...and develops facility P&Ps, training programs, and screening and prevention systems to promote an environment free from abuse ...and mistreatment. Review of the SOC-341 (Report of Suspected Dependent Adult/Elder Abuse) dated 11/6/23, showed Resident 1 sustained a laceration to his left eye with swelling. Resident 1 was sent to Acute Care Hospital 1 for evaluation. Resident 2 stated Resident 1 took his milk and he hit him in the eye. 1. Medical record review for Resident 2 was initiated on 11/8/23. Resident 2 was readmitted to the facility on 1/9/23. Review of Resident 2's care plan dated 12/8/22, showed a care plan focus addressing Resident 2 was at risk for harm: self-directed or other-directed. Review of Resident 2's Health Status Note dated 11/6/23, showed Resident 1 snatched Resident 2's milk from his hand. The note showed Resident 2 stated when Resident 1 resisted from letting go of the milk, Resident 1 punched Resident 2 on his face, then Resident 2 proceeded to punch Resident 1 on his face. 2. Medical record review of Resident 1 was initiated on 11/8/23. Resident 1 was admitted to the facility on 10/18/23, with diagnoses including paranoid schizophrenia (a brain disorder which causes people to interpret reality abnormally) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of Resident 1's History & Physical examination dated 10/18/23, showed Resident 1 could make his needs known but could not make medical decisions. Review of Resident 1's Health Status Note dated 10/18/23, showed Resident 1 was newly admitted and noted by the staff that Resident 1 kept entering other residents' rooms and eating other people's foods. Review of Resident 1's care plan dated 10/18/23, showed a care plan focus addressing Resident 1 was a risk for wandering/elopement. The care plan interventions included to clearly identify the resident's room and bathroom; engage the resident in the purposeful activity; identify if there was certain time of the day wandering/elopement attempts occurred; implement a scheduled toileting program; provide clear, simple questions; provide reorientation to surroundings; and schedule time for regular walks or appropriate activities. Review of Resident 1's Health Status Note dated 11/6/23, showed at 1100 hours, Resident 1 was seen walking into other residents' rooms. Resident 1 was placed on 1:1 supervision with the RNA due to the resident constantly going into everyone's rooms. At 1500 hours, Resident 1's room was changed due to needing a 1:1 sitter, and the sitter was in the room with Resident 1. At 1805 hours, Resident 2 was standing by the doorway with the seemingly extremely angry facial expression and noted with blood on his gown. Resident 1 was a few feet away bleeding from his left side of face. Resident 1 noted with a laceration to the left side of the face with swelling and bleeding noted. Resident 1 stated, "That guy punched me. " Review of Resident 1's Change in Condition Evaluation dated 11/6/23, showed upon notification of the altercation, Resident 1's provider recommended for Resident 1 to be sent to the acute care hospital via 911 for further evaluation and treatment. Review of Resident 1's medical record from Acute Care Hospital 1 showed Resident 1 was admitted to Acute Care Hospital 1 on 11/6/23. Review of Resident 1's Admission History and Physical, Adult assessment from Acute Care Hospital 1 dated 11/6/23, showed Resident 1 reported being hit "11 times. " Resident 1 was assessed to have nasal swelling with dried blood in his nares; left periorbital ecchymosis and swelling, and a left upper eyelid superficial laceration. Review of Resident 1's Progress Notes from Acute Care Hospital 1 dated 11/7/23, showed Resident 1 suffered from the blunt head and facial trauma, a traumatic brain injury/cerebral concussion, a left nasal bone fracture, and left periorbital (around the eye) soft tissue swelling. On 11/8/23 at 1535 hours, an interview was conducted with RN 1. RN 1 verified Resident 1 would wander into other residents' rooms often and stated Resident 1 was placed on 1:1 supervision on that day. RN 1 stated the 1:1 sitter had two residents (Residents 1 and 4) to watch 1:1 and went to bring Resident 4 out to smoke when Resident 1 got hit by Resident 2. On 11/8/23 at 1334 hours, an interview was conducted with LVN 3. LVN 3 was asked about the events that took place on 11/6/23, between Residents 1 and 2. LVN 3 stated he was the first responder to the incident after an RNA yelled for help. LVN 3 stated he saw Resident 2 standing outside a resident's room door and Resident 1 was walking out with his eye covered. LVN 3 described Resident 1 had his eyes closed and was trying to wipe off the blood from his face. LVN 3 also observed Resident 1 with swelling, discoloration, and skin tear on the eyelid. On 11/8/23 at 1607 hours, an interview was conducted with CNA 2. CNA 2 stated on 11/6/23, she was assigned to Resident 1 as a 1:1 supervision, but the facility also assigned her to care for three other residents. CNA 2 stated Resident 1 had dementia and went all the time to each room and took things from other residents. CNA 2 stated at 1750 hours, Resident 4 (one of the CNA's other assigned residents) went to the line to smoke, and she had to follow Resident 4. CNA 2 stated no one was covering for her to watch Resident 1 when she left the room. CNA 2 added within 10 minutes, she heard an RNA screaming for help from the residents' room due to the altercation. On 11/16/23 at 1036 hours, the Administrator was informed of and acknowledged the above findings. The Administrator acknowledged Resident 1 was placed on a 1:1 monitoring; however, Resident 1 was left unattended and wandered into Resident 2's room, which resulted in Resident 2 striking at and causing injury to Resident 1 with hospitalization. This violation had a direct or immediate relationship to the health, safety or security of the client.