Other·January 8, 2024

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 and medical record review, the facility failed to protect the residents' (Residents 1 and 3) right to be free from physical abuse by Residents 2 and 4. * Resident 2 had episodes of aggressive behaviors and refused the antipsychotic medications ordered by the physician. The facility failed to notify the psychiatrist that Resident 2's refusal as ordered which resulted in Resident 2's increase in agitation. Resident 2 struck Resident 1 on the face with a pitcher which resulted in Resident 1 sustaining head trauma and injuries on her face, arms, and legs. * Resident 4 punched Resident 3 in the face when Resident 3 refused to turn off a room light. This caused injuries to Resident 3's nose and upper lip. Findings: 1. Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 11/19/23, showed Resident 2 hit Resident 1 causing bleeding on Resident 1's face, arms, and legs. a. Medical record review for Resident 1 was initiated on 11/29/23. Resident 1 was admitted to the facility on 3/4/21, and readmitted on 10/6/23. Review of Resident 1's MDS dated 10/11/23, showed Resident 1 had moderately cognitive impairment. Review of Resident 1's Change in Condition Evaluation dated 11/19/23 at 2141 hours, showed at 1615 hours, at Room A, the front door was closed with Resident 2 (Resident 1's roommate) holding the door shut with her body. When the front door was opened, Resident 1 was found crying, stating "...she hit me, she hit me..." with bleeding from her face, bilateral arms, and legs. Resident 1 was transferred to the acute care hospital for evaluation. Resident 2 was asked why she hit Resident 1, and Resident 2 stated "...because I love her so much." Under the skin status evaluation, it showed Resident 1 had skin tears and abrasions on the top of her scalp, face, right and left elbows, and bilateral lower extremities. Review of Resident 1's medical record from the acute care hospital dated 11/19/23, showed Resident 1 was assessed to have multiple facial and body scratches and abrasions after an alleged assault. Resident 1 was admitted to the acute care hospital with diagnoses of blunt head trauma, facial contusion, abrasions of multiple sites and multiple contusions post alleged assault. b. Medical record review for Resident 2 was initiated on 11/29/23. Resident 2 was admitted to the facility on 8/15/23. Review of Resident 's MDS dated 8/21/23, showed Resident 2 was cognitively intact. Review of Resident 2's care plan dated 8/16/23, showed a care plan problem addressing Resident 2 was at risk for harm: self-directed or other-directed related to schizoaffective disorder, anxiety disorder, depression, and insomnia. The interventions were to notify the provider if Resident 2 posed a potential threat to injure self or others, monitor sign and symptoms of agitation, and monitor for cognitive, emotional, or environmental factors contributing to violent behaviors. Review of Resident 2's Order Recap Report from 8/1/23 to 12/31/23, showed the following physician's orders: - dated 8/15/23, to administer one tablet of olanzapine (an antipsychotic that can treat schizophrenia and bipolar disorder) 20 mg by mouth two times a day for schizophrenia manifested by talking to unseen others, discontinued on 10/18/23; - dated 8/19/23, to administer two tablets of vortioxetine (an antidepressant used to treat major depressive disorder) 10 mg by mouth in the morning for depression manifested by verbalization of sadness; - dated 10/17/23, to inject Invega Sustenna (medication that can treat schizophrenia and schizoaffective disorder) 234 mg intramuscularly (in the muscle) one time a day starting on the 17th and ending on the 17th of every month for manifested by aggressive behavior and paranoid delusion. Review of Resident 2's physician's order dated 9/9/23, showed the order to notify the psychiatry NP if Resident 2 was refusing the medications. Review of Resident 2's Medication Administration Record for October 2023 showed Resident 2 had refused to take the following medications on the following dates: - olanzapine 20 mg on 10/1 at 0800 hours, 10/5 at 1700 hours, 10/9 at 0800 and 1700 hours, 10/10 at 0800 hours, and 10/16/23 at 0800 hours; and, - vortioxetine 10 mg on 10/1, 10/9, 10/10, 10/16, 10/20, 10/21, 10/22, 10/27, and 10/28/23. Review of Resident 2's Medication Administration Record for November 2023 showed Resident 2 had refused to take the following medication on the following dates: - Invega Sustenna 234 mg on 11/17/23; and, - vortioxetine 10 mg on 11/3, 11/5, 11/11, 11/17, 11/18, and 11/19/23. Review of Resident 2's medical record failed to show Resident 2's psychiatric team was notified of Resident 2 refusing to take the above medications. Further review of Resident 2's medical record failed to show Resident 2 was being monitored for aggressive behaviors and paranoid delusions. Review of Resident 2's Change in Condition Evaluation dated 9/28/23 at 1535 hours, showed Resident 2 was agitated towards the staff and other residents. When the staff attempted to deescalate Resident 2, Resident 2 continued to yell and walked towards the staff to hit them. Review of Resident 2's Progress Notes dated 10/18/23 at 0405 hours, showed Resident 2 was yelling at people in her room all throughout the night. Resident 2 was reminded she was alone in her room, but Resident 2 insisted there were spirits with her. Resident 2 was progressively getting louder and more aggressive, used slurred speech, and was slamming on doors. Review of Resident 2's Change in Condition Evaluation dated 11/19/23 at 2156 hours, showed at 1615 hours, a CNA reported residents (Residents 1 and 2) were fighting. When walking to Resident 2's room, the front door was closed with Resident 2 holding the door shut with her body. When the front door was pushed opened, Resident 1 was found crying, stating "...she hit me, she hit me..." with bleeding to the face, bilateral arms, and legs. Resident 1 was transferred to the acute care hospital for evaluation. Resident 2 was asked why she hit Resident 1, and Resident 2 stated "...because I love her so much." On 11/29/23 at 1210 hours, an interview was conducted with the ADON. The ADON stated CNA 1 came to her asking for help. When they walked to Resident 2's room, the door was closed, Resident 2 held the door shut. When the door was pushed open, Resident 1 was found with bleeding on her face, arms, and legs. Resident 2 admitted to the police that she had hit Resident 1 with a pitcher. On 11/30/23 at 0936 hours, an interview was conducted with CNA 1. CNA 1 stated he heard Resident 1 screaming. When he walked into the room, CNA 1 saw Resident 2 standing next to Resident 1's bed. Resident 1 was lying in bed and could not get up. Resident 1 appeared hurt with scratches all over her face, arms, and legs. On 12/4/23 at 1055 hours, an interview and medical record review was conducted with LVN 1. LVN 1 stated Resident 2 was unpredictable, could be polite; however, she had sudden outbursts. LVN 1 was asked if Resident 2's psychiatrist was notified of Resident 2's multiple episodes of refusing her medications ordered by the physician. LVN 1 stated he called and texted Resident 2's medical physician, however, failed to notify the psychiatry health practitioners or psychiatrist regarding Resident 2's episodes of refusing the medications. 2. Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 11/28/23, showed Resident 3 got punched by his roommate. LVN 2 heard a noise from the room and saw Resident 3 was standing in front of Resident 4. Resident 4 had his left hand balled up and was observed bleeding. Resident 3 was also observed bleeding from his nose and upper lip. a. Medical record review for Resident 3 was initiated on 11/29/23. Resident 3 was admitted to the facility on 11/22/22. Review of Resident 3's History and Physical Examination dated 11/22/23, showed Resident 3 could make his needs known but could not make medical decisions. Review of Resident 3's Change in Condition Evaluation dated 11/27/23 at 2115 hours, showed LVN 2 heard a loud commotion inside the room while the door was closed. When LVN 2 entered room, he saw Resident 4 standing in front of Resident 3 in between resident beds. Resident 4 was standing with his fist balled up and bleeding. Resident 3 was noted with his nose bleeding and a small scratch to the upper lip measuring 0.2 cm x 0.2 cm. When LVN 2 asked residents what happened, Resident 3 stated, "... he [Resident 4] hit me because of the light." b. Medical record review for Resident 4 was initiated on 11/29/23. Resident 4 was originally admitted to the facility on 2/18/22, and readmitted on 11/17/22. Review of Resident 4's MDS dated 10/14/23, showed Resident 4 was cognitively intact. Review of Resident 4's Progress Note dated 11/27/23, showed at 11/27 at approximately 2115 hours, a facility staff member heard a loud noise coming from Residents 3 and 4's room. When the facility staff entered the closed room, Resident 4 had his left fist balled up and bleeding from that hand. Resident 4 stated he repeatedly requested for Resident 3 to turn off the light; however, Resident 3 refused and insisted the light would stay on all the time. Resident 4 stated he went to Resident 3's side of the room to turn off the light; however, Resident 3 did not let him. Resident 4 stated Resident 3 attempted to punch him; however, Resident 4 punched Resident 3 first. The Progress Note showed Resident 4 suffered a left-hand abrasion measuring 2.5 cm x 0.2 cm, from the altercation. Review of Resident 4's Progress Notes dated 11/28/23, showed Residents 3 and 4 had an altercation when Resident 4 punched Resident 3 in the face after Resident 3 refused to turn off the light in the room they share. Resident 4 sustained a laceration to the left hand after punching Resident 3. On 12/4/23 at 1520 hours, an interview and medical record review was conducted with RN 1. RN 1 stated LVN 2 reported Resident 3 wanted to turn his room light on; however, Resident 4 wanted the light off. Resident 4 then went to Resident 3's bed to turn off the light. Resident 3 did not want Resident 4 to turn off the light. Resident 3 wanted to hit Resident 4, but before he could hit Resident 4, Resident 4 punched him instead. This violation had a direct or immediate relationship to the health, safety or security of the residents.