Other·April 17, 2024

The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a Facility Reported Incident CA00807582. Event ID: 817N11 Exit date: 3/19/24 Representing the Department: 2651, Health Facilities Evaluator Nurse State Citation B was issued. §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. On 3/19/24, an unannounced visit was conducted at the facility to investigate a Facility Reported Incident regarding Resident Abuse. The facility failed to ensure residents were free from physical abuse when Resident 2 slapped Resident 1 in the mouth causing injury to Resident 1's top lip and first aid being administered. This failure had the potential of both physical and emotional harm to all residents. On 10/17/22, the facility submitted a facsimile (FAX, a telephonic transmission of scanned printed material) to the California Department of Public Health (CDPH) about an incident between Residents 1 and 2. The FAX indicated Resident 2 slapped Resident 1 in the mouth and Resident 1 sustained a minor injury of the upper gingiva (gums) and upper lip. Review of Resident 1's clinical record indicated she had diagnoses which included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), sepsis (an infection in the blood). Review of Resident 2's clinical record indicated he had diagnoses which included schizoaffective disorder (mental disorder including schizophrenia [serious mental disorder in which people cannot distinguish reality] and mood disorder) and bipolar disorder (mental illness which a person can experience mood swings [period of overly happy or periods of feeling sad). Review of the facility's 5-day summary report, dated 10/19/22, indicated, on 10/15/22 at 12:10 p.m., staff were bringing residents in the dining room and found Resident 1 placing her hand on mouth. The 5-day summary report further indicated Resident 1 had a slight upper lip bleeding. Residents in the dining room witnessed Resident 2 slapping Resident 1 after a verbal altercation (argument). Review of Resident 2's IDT Progress Notes-Behavior Management, dated 10/17/22, indicated, on 10/15/22 Resident 2 went to the dining room, pulled a chair out from a table which made a loud noise. The noise had agitated Resident 1 and she made a comment to Resident 2 to "pick up your chair." Resident 2 walked over to Resident 1 and stated, "Please don't say that sh**" and Resident 1 had responded back "you have so much anger in you, why don't you just hit me." Resident 2 proceeded to slap Resident 1 in the mouth causing Resident 1 to bleed form her lip. Review of Resident 1's skin assessment, dated 10/15/22, indicated she had pain with an intensity of 9 (scale of 0 being no pain and 10 being excruciating pain). There was a slight bleeding in the upper gingiva (gum) and swelling of left upper and lower lip. During a telephone interview with the administrator (ADM) on 2/23/24 at 9:47 a.m., the ADM stated the facility considered the incident as an abuse because the facility submitted a SOC 341 (a document used to report elderly abuse). The ADM further stated if the facility does an SOC 341, the facility had substantiated the abuse/altercation. During a telephone interview with the ADM on 3/27/24 at 10:45 a.m., she stated the incident between Residents 1 and 2 was witnessed by a resident. The ADM confirmed that Residents 1 and 2 had a verbal altercation. The altercation lead Resident 2 slapping Resident 1 in the mouth. Review of the facility's policy and procedure, "Abuse Prohibition Policy and Procedure" indicated, "Healthcare centers prohibits abuse...Abuse is defined as the willful infliction of injury...Physical Abuse includes hitting, slapping..." The facility failed to ensure residents were free from physical abuse when Resident 2 slapped Resident 1 in the mouth causing injury to Resident 1's top lip and first aid being administered. This failure had the potential of both physical and emotional harm to all residents. The above violation had a direct or immediate relationship to the health, safety, or security of the residents.