Health inspection·July 11, 2022

The following reflects the findings of the California Department of Public Health during the investigation of entity reported incident CA00785825 and complaint CA00786125. Representing the Department: Health Facilities Evaluator Nurse, 43763 F603 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.12 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. On 5/26/2022, an unannounced visit was conducted at the facility for the investigation of an entity reported incident and a complaint. The facility failed to follow its policy and maintain an environment free of involuntary seclusion for one of three sampled residents (Resident 1) when certified nursing assistant A (CNA A) prevented Resident 1 from being able to freely leave her room by tying a pillowcase from the doorknob of the resident's room to the adjacent handrail in the hallway preventing the resident from leaving. This deficient practice violated Resident 1's right to be free from involuntary seclusion and had the potential for harm to the resident both physically and psychosocially. Review of Resident 1’s face sheet, undated, indicated she is a 72-year-old female with history of a traumatic subdural hemorrhage (injury to head which causes bleeding inside the skill and pressure in the brain which can result in changes to mood, concentration, language skills, and memory problems) and vascular dementia (brain damage caused by multiple strokes). Review of Resident 1’s cognitive assessment in the minimum data set (MDS; tool used for assessment), dated 5/12/2022, indicated the resident had severe cognitive impairment. During observation of Resident 1, on 5/262022 at 3:10 p.m., Resident 1 was asleep on her mattress on the floor. During interview with CNA A, on 5/26/2022 at 1:30 p.m., CNA A stated on 5/22/2022 at 3:45 a.m., Resident 1 was shouting and yelling in her room. She stated she tied a pillowcase to the doorknob and then to the handrail in the resident hallway which made it impossible for the resident to open the door. She stated she thought this was for Resident 1’s safety because Resident 1 would be unable to leave the room. CNA A stated that she would be down the hall and assisting another CNA with resident care, and she did not want Resident 1 to leave her room and disrupt other residents. She stated the door was tied shut for about 15 minutes. She confirmed tying the door shut was seclusion and considered abuse. She stated she should not have tied the pillowcase from the doorknob of the resident's room to the adjacent handrail. During record review of the Resident Progress Note for Resident 1 with registered nurse F (RN F), dated 5/22/2022 at 4:05 a.m., it indicated Resident 1’s room was secured shut with a pillowcase tied to the door handle and then the handrail in the hallway. This could have prevented Resident 1 from opening the door to the hallway. The note further indicated CNA A acknowledged she tied the door shut because the resident was screaming and did not want the resident to disturb other residents. During interview with RN F, on 5/26/2022 at 2:16 p.m., he stated CNA A stated she tied Resident 1’s door shut, on 5/22/2022 around 3:45 a.m., and stated he discussed with her that it was seclusion, and it was considered abuse. He confirmed she continued to work for the rest of her shift until roughly 7:00 a.m. and stated he probably should have sent her home for the rest of her shift. During interview with licensed vocational nurse B (LVN B), on 5/26/2022 at 3:06 p.m., he stated the facility is seclusion free and that it is never appropriate to tie anything to a door and to a side rail. He stated seclusion is false imprisonment and is abuse. He stated Resident 1 is not what he would consider a difficult resident. He stated she gets frustrated because she cannot communicate at times due to her brain injury. He stated she likes snacks as a distraction. During interview with licensed vocational nurse C (LVN C), on 5/26/2022 at 3:06 p.m., she confirmed tying the door closed was abuse and seclusion. During interview with licensed vocational nurse D (LVN D), on 5/26/2022 at 3:06 p.m., she confirmed tying the door closed was abuse and seclusion. During interview with registered nurse E (RN E), on 5/26/2022 at 3:06 p.m., she confirmed tying the door closed was abuse and seclusion. During interview with licensed vocational nurse F (LVN F), on 5/26/2022 at 3:06 p.m., she confirmed tying the door closed was abuse and seclusion. During interview with registered nurse G (RN G), on 5/26/2022 at 3:06 p.m., she confirmed tying the door closed was abuse and seclusion. During review of the facility’s "Investigation Summary”, dated 5/22/2022, indicated the door was tied from the door handle to the handrail in the hallway. The investigation confirmed CNA A admitted to tying the door shut. Record review of the facility’s policy "Abuse Prevention Program," revised 5/28/2019, indicated the facility’s residents have the right to be free from abuse which includes involuntary seclusion. The facility failed to follow its policy and maintain an environment free of involuntary seclusion for one of three sampled residents (Resident 1) when certified nursing assistant A (CNA A) prevented Resident 1 from being able to freely leave her room by tying a pillowcase from the doorknob of the resident's room to the adjacent handrail in the hallway preventing the resident from leaving. These failures violated Resident 1's right to be free from involuntary seclusion and had the potential for harm to the resident both physically and psychosocially. This violation had a direct or immediate relationship to the health, safety, or security of the resident.