Health inspection·February 17, 2022

F607 Develop/Implement Abuse Neglect Policies §483.12(b)(1)-(3) §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, §483.12(b)(3) Include training as required at paragraph §483.95 Prohibit and prevent abuse, neglect, and exploitation of Patients and misappropriation of Patient property During a complaint investigation on completed on 2/17/22, the California Department of Public Health determined the facility failed to follow their own abuse policies to prevent abuse when Patient 1, who had a history of displaying sexual behaviors, did not have comprehensively behavioral care plans developed and the patient was not adequately supervised to prevent a recurrent incident with a second patient (Patient 2). This failure resulted in Patient 2 being subject to Patient 1's inappropriate behavior and placed other patients at risk for sexual abuse. During an observation on 1/27/22 at 10:30 a.m., Patient 1 was standing and walking in his room independently. Patient 1 grabbed her hands and held on when the social services director (SSD) approached him for an interview. Review of Patient 1's record indicated he had diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and psychotic disorder (severe mental disorder that cause abnormal thinking and perceptions). Review of Patient 1's Minimum Data Set (MDS, an assessment tool), dated 12/23/21, indicated the patient had severe difficulty in daily decision-making skills. Patient 1 had a physician's order dated 12/17/21 for Risperdal (anti-psychotic medication) 0.5 milligram (mg, a metric unit of measurement) twice daily for psychosis. Patient 1 also had a physician's order dated 10/28/21 indicating to monitor number of behaviors to include episodes of sexual, verbal, acts/exhibits toward staff. Review of Patient 1's Health Status Note, dated 9/22/21 at 5:01 p.m., indicated Patient 1 had an inappropriate conversation with a certified nurse assistant (CNA), exposed himself, attempted to touch the CNA, and did not wear a brief after showering. Review of Patient 1's Health Status Note, dated 9/22/21 at 10:23 p.m., indicated the resident pulled out his penis to a staff member and stated, "suck on my penis." Review of Patient 1's Change of Condition Evaluation (COCE) form, dated 12/3/21 at 12:11 p.m., indicated in the afternoon of 12/3/21, the resident was accused of sexual harassment by another patient (Patient 3). Patient 3 stated a man touched her breasts and she pointed at Patient1. A single approach to monitor behavior and ensure Patient 1 was away from Patient 3 was implemented. Review of Patient 1's behavioral care plan identified the resident was at high risk for wandering (moving from place to place without a fixed plan) dated 9/21/21, and a care plan dated 12/3/21, indicating he "touched her breast yesterday" with one intervention for staff to monitor resident whereabouts to not to get close this female resident. Given that Patient 1 displayed sexual behaviors towards staff, the record lacked an assessment indicating if he was at risk to patients and there were no prior care plan addressing his inappropriate sexual behaviors. During an observation and interview on 1/27/22 at 1:10 p.m., Patient 3 stated when she was in the activity room trimming a Christmas tree, a male resident approached her and patted her breast. Patient 3 then patted her breast with her hand to show what happened. Patient 3 stated she was startled, told him not to do it and he did it again. During a second interview on 1/27/22 at 1:31 p.m., Patient 3 sought out the evaluator and stated the name of the male patient (Patient 1) who patted her breast. Review of Patient 1's COCE form, dated 1/21/22 at 9:31 a.m., indicated a female resident went into his room and Patient 1 attempted to go on top of her. Review of Patient 2's Health Status Note, dated 1/24/22 at 10:24 a.m., indicated a CNA saw Patient 2 lying on her back on the bed with her feet on the ground and her pants and brief down to her knees. Patient 2 was standing in front of her. Resident 2 then stated she went to the room because Patient 2 asked her to interpret something for him. Review of Patient 1's The Interdisciplinary Team (IDT, different members of the health care providers that meet to discuss and plan care for the resident) Progress Note, dated 1/24/22 at 10:28, indicated Patient 1 was placed on enhanced supervision for his whereabouts and encouraged to attend activities. Further review of Patient 1's behavioral care plans included the use of psychotropic medications Risperdal related to inappropriate sexual behavior of touching other residents, dated 12/17/21; and physical aggression, attempted to go on top of a female patient, dated 1/21/22. The 1/21/22 physical aggression care plan had preventative interventions of separating patients and to monitor the whereabouts and not let Patient 1 get close to female residents. Review of Patient 2's record indicated she left the facility against medical advice the afternoon of 1/21/22. During an interview on 1/27/22 at 11:27 a.m., CNA A stated last Friday (1/21/22)she found Patient 2 lying on Resident 1's bed on her back with her pants and brief below her knees. Patient 2 was trying to pull his pants down and he was standing next to patient 1. The CNA A stated she got there just in time to prevent anything from happening. During an interview on 1/31/22 at 1:10 p.m., CNA B stated her current assignment was ten patients on both sides of the building including Patient 1. CNA B stated she did not know and if she had known about Patient 1's sexual behavior she would have watched him more closely. CNA B then looked in a computer and stated she did not find a section in point click care to document the monitoring of Patient 1. During an interview on 1/31/22 at 3:34 p.m., the registered nurse (RN) stated Patient 1 had used his hands to gesture to come over and he pointed his finger at his crotch. The RN stated she saw Patient 2 sitting on Patient 1's bed on the day of the 1/21/22 incident. During an interview on 1/31/22 at 2:35 p.m., the director of nurses (DON) stated after the 12/3/21 incident nurses were documenting Patient 1's monitoring by documenting it every shift for three days (alert charting). The DON did not find documentation of Patient1 being monitored after the third day and stated patients besides Patient 2 could be at risk. The DON did not offer any comment as to why the 12/3/21 behavioral care plan was limited to monitor Patient 1 for only three days and stated the behavioral care plans were not comprehensive. During the same interview as above on 1/31/22 at 2:55 p.m., the DON stated Patient 1 was on enhanced supervision after the 1/21/22 incident but could not find documentation to support this intervention was carried out. Review of the Abuse Prohibition and Prevention Policy and Procedure policy, under Protection, revised 03/2018, indicated the facility was to ensure all residents were protected from physical and psychosocial harm during and after the investigation. If the suspected perpetrator was another resident to provide increased supervision to the alleged to residents. Review of the Managing Resident-to-Resident Altercations policy, revised 11/6/17, indicated to develop a care plan that included interventions to minimize or prevent the reoccurrence of such incidents, including the appropriate management of any underlying conditions, resident triggers, environmental factors and any other related root cause findings. This violation had a direct or immediate relationship to the health, safety, or security of the patients.