Health inspection·October 16, 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, medical record review, facility document review, and facility P&P review, the facility failed to protect the patients' (Patients 2 and 4) rights to be free from the sexual abuse by another patient (Patient 3). * The facility failed to monitor and provide Patient 3 with the 1:1 (one staff to one patient) supervision as per the care plan after an incident of Patient 3 grabbing Patient 2's breasts on 9/6/24, resulting in Patient 3 continuing to fondle Patient 4's breasts during the activities in the dining room on 9/8/24. This failure resulted in Patient 3 continuing to sexually abuse other patients. Findings: Review of the facility's P&P titled Abuse Prevention Program revised 4/2021 showed the patients have the right to be free from abuse, neglect, misappropriate of patient property, and exploitation, which included freedom from sexual abuse. The patients are protected from abuse by anyone including other patients. In addition to protecting patients from any further harm during investigations. Review of the facility's P&P titled Abuse, Neglect, Exploitation, or Misappropriation Reporting and Investigation revised 4/2024 showed upon receiving any allegations of abuse, neglect, exploitation, misappropriation of patient property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of patients. Review of the facility's P&P titled Care Plans, Comprehensive Person Centered revised 12/2016 showed, identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the patient, are the endpoint of an interdisciplinary process. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship the patient's problem areas and their causes, and relevant clinical decision making. On 9/7/24 at 1408 hours, the CDPH, L&C Program received an SOC 341 from the facility showing Patient 2 reported to the charge nurse alleging Patient 3 had grabbed her right breast on 9/6/24 at 2345 hours. On 9/10/24 at 1715 hours, the CDPH, L&C Program received an SOC 341 from the facility showing Patient 3 had fondled Patient 4's breasts in the dining room on 9/8/24. 1. Medical record review for Patient 2 was initiated on 9/10/24. Patient 2 was admitted to the facility on 10/23/20, and readmitted on 8/22/24. Review of Patient 2's H&P examination dated 6/3/24, showed Patient 2 had the capacity to understand and make decisions. Review of Patient 2's MDS dated 8/25/24, showed Patient 2 was cognitively intact with a BIMS score of 15. Review of Patient 2's SBAR Communication Form dated 9/7/24, showed Patient 2 reported to staff another patient (Patient 3) grabbed her right-side breast on 9/6/24 at 2345 hours, at the smoking patio. The form further showed Patient 2 felt upset. On 9/10/24 at 1036 hours, an interview was conducted with Patient 2. Patient 2 stated on 9/6/24 at 2345 hours, while she was coming in from the smoking patio, Patient 3 stated, "oh boobies," then grabbed her both breasts. Patient 2 stated Patient 3 squeezed so hard that hurt her right breast. Patient 2 further stated the following day when she walked by Patient 3 who again stated "oh boobies" in front of other people and families. On 9/11/24 at 0835 hours, a follow-up interview was conducted with Patient 2. Patient 2 stated she felt violated and embarrassed and stated that was the first man to ever touch her ever since her husband passed away in 2011. 2. Medical record review for Patient 4 was initiated on 9/10/24. Patient 4 was admitted to the facility on 8/21/24. Review of Patient 4's MDS dated 8/28/24, showed Patient 4 was moderately impaired with a BIMS score of 11. Review of Patient 4's SBAR Communication Form dated 9/8/24, showed Patient 4 reported her breast was fondled by another patient (Patient 3) while they were in the activity room. On 9/10/24 at 1129 hours, an interview with the DON was conducted. The DON verified Patient 3 grazed his hands over Patient 4's chest which was witnessed by the Activities Assistant. On 9/10/24 at 1346 hours, an interview was conducted with Patient 4. Patient 4 stated while sitting in the activities room, Patient 3 had reached over, touched her breasts, and laughed and kept doing it. Patient 4 further stated she told Patient 3 to stop, then she got up and moved. When asked if anyone else saw the incident, Patient 4 stated the Activities Assistant saw and told Patient 3 to stop. On 9/10/24 at 1401 hours, an interview was conducted with the Activities Assistant. The Activities Assistant stated on 9/8/24 at 1015 hours, Patient 4 was sitting next to Patient 3 in the dining room for activities when Patient 3 kept reaching his hand over Patient 4 and touching Patient 4's breasts with an open palm. When asked if she witnessed the incident, Activities Assistant stated "yes." 3. Closed medical record review for Patient 3 was initiated on 9/10/24. Patient 3 was admitted to the facility on 8/20/24, and discharged on 9/8/24. Review of Patient 3's SBAR Communication Form dated 9/7/24, showed a report was received Patient 3 grabbed a patient's right breast on 9/6/24 at 2345 hours, in the smoking patio. Review of Patient 3's SBAR Communication Form dated 9/8/24, showed Patient 3 was brought to the dining room for the activity time, and Patient 3 kept trying to fondle a female patient's chest even after multiple warnings by the female patient telling Patient 3 to stop. Review of Patient 3's MDS dated 8/27/24, showed the Section GG for Functional Limitation in Range of Motion for the upper extremity (shoulder, elbow, wrist, hand) indicated "0" (no impairment). Review of Patient 3's Plan of Care showed a care plan problem initiated on 9/7/24, addressing the report of Patient 3 grabbed a patient's right breast at the smoking patio. The care plan goal showed "no grabbing other breast behavior on next review date." The care plan interventions included to conduct the frequent visual checks and provide the 1:1 sitter. Review of the facility's Daily Assignment Sheets for 9/7 and 9/8/24, showed the LVNs and CNAs were assigned to multiple patients per shift. Further review of the assignment sheets failed to show documented evidence a staff was assigned to conduct the 1:1 sitter for Patient 3. On 9/11/24 at 1014 hours, an interview was conducted with RN 1. RN 1 stated the 1:1 sitter would consist of one nurse or one CNA to one patient, and the staff would be with the patient at all times to ensure the patient's whereabouts. RN 1 verified there was no documented evidence Patient had the 1:1 sitter after the first incident on 9/6/24, with Patient 3 as per the care plan initiated on 9/7/24, until after the second abuse allegation with Patient 4 on 9/8/24. On 9/12/24 at 1340 hours, an interview was conducted with LVN 5. LVN 5 verified Patient 3 did not have the 1:1 sitter on 9/7 - 9/8/24, prior to the second allegation due to short of staff. LVN 5 stated if Patient 3 was provided a sitter, the 1:1 sitter would also accompany the Patient 3 during the activity time. On 9/13/24 at 1024 hours, a follow-up interview was conducted with the Activities Assistant. The Activities Assistant stated there were no other staff members in the room during the activities on 9/8/24. The Activities Assistant verified Patient 3 did not have the 1:1 sitter in the dining room. On 9/17/24 at 1349 hours, an interview was conducted with CNA 4. CNA 4 verified she was assigned to Patient 3 on 9/8/24. When asked what her role was with Patient 3, CNA 4 stated "I needed to monitor him." When asked how many other patients she had on 9/8/24, CNA 4 stated she had eight or nine patients. When asked who was monitoring Patient 3, CNA 4 stated, "me I guess." When asked how Patient 3 got into the activities room, CNA 4 stated she assisted Patient 3 to get dressed and Patient 3 self-propelled himself in his wheelchair into activities. When asked if anyone accompanied Patient 3 in the activities room, CNA 4 stated "no." When asked if anyone was watching Patient 3 during activities, CNA 4 stated, "not that I'm aware." When asked if Patient 3 was being monitored prior to the second abuse allegation with Patient 4, CNA 4 stated, "not that I'm aware." On 9/17/24 at 1450 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings. This violation had a direct or immediate relationship to the health, safety or security of the patients.