Health inspection·February 14, 2024

SKYLINE HC F600 The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident # CA00859829 Event ID: 99ZV11 Representing the Department, HFEN # 44733 State Citation B was written. 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. Title 22 § 72315. Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. Title 22 § 72523. Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Title 22 § 72527. Patient's Rights (a) Patient have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patient shall have the right: (10) To be free from mental and physical abuse. On 9/13/2023 at 3:15 p.m., an unannounced visit was conducted at the facility for an abbreviated survey. Based on observation, interview, and record review, the facility failed to ensure residents were free from verbal and physical abuse for two of three residents (Residents 1 and 2) when: 1. Resident 1 sustained facial injuries when Resident 2 scratched her in the face and was transferred to the emergency room (ER). 2. Resident 2 sustained emotional distress by feeling upset when Resident 1 said bad words, and complained of pain on her breast when Resident 1 grabbed her breast. This failure had caused both emotional and physical harm to Residents 1 and 2. Findings: On 9/08/2023, the facility submitted a facsimile (FAX) to the California Department of Public Health (CDPH) about an incident between Residents 1 and 2. The FAX showed Residents 1 and 2 had verbal arguments. Resident 1 grabbed Resident 2's breast, and Resident 2 grabbed Resident 1's hair and scratched her in the face. During a review of the facility's investigative summary dated 9/13/2023, the summary indicated Resident 1 and 2 were outside of the facility by the front of the building on 9/08/2023 around 10:30 a.m. when they had a verbal argument. Resident 1 and 2 started a verbal argument, Resident 2 wheeled away, but Resident 1 said something bad to Resident 2. Resident 2 spit in Resident 1's direction, then Resident 1 grabbed Resident 2's breast. Resident 2 pulled Resident 1's hair and scratched Resident 1's left side of the face. Review of Resident 1's clinical record indicated she was admitted on 8/06/2023 and had diagnoses including psychotic disorder (a mental disorder characterized by a disconnection from reality) with hallucinations (seeing or hearing things that others do not), depressive episodes (experiences of feeling sad, irritable, and empty), and opioid (a broad range of drugs used to reduce pain, including illegal drugs) dependence. Her Minimum Data Set (MDS, an assessment tool) dated 8/12/2023, indicated a Brief Interview for Mental Status (BIMS) score of 15 (intact cognition). During a review of Resident 1's Psychiatry Visit Progress Report dated 6/21/2023, the report indicated Resident 1 had a history of psychotic disorder with hallucinations, depressive episodes, and opioid dependence. The report also indicated treatment goals were stabilization of depressed mood, stabilization of irritability/anger and increasing appropriate expression of angry feelings. During a review of Resident 1's care plan for negative/untoward event resident to resident verbal aggression, created on 8/22/2023, the care plan indicated interventions, including one on one sitter provided for close observation and safety. During a review of Resident 1's physician order, dated 8/22/2023, the order indicated "1 to 1 sitter (staff that are immediately at hand can help prevent an accident or redirect a patient from engaging in a harmful act)." During a review of Resident 1's situation, background, assessment, and recommendation (SBAR) dated 9/08/2023, the SBAR indicated an altercation with a skin tear: at 11:02 a.m., CNA (Certified Nursing Assistant) met the writer at the front, reporting that the resident gave her debit card to a male resident, and the staff went back to attend the resident. As the writer was walking outside, the writer saw commotion between two residents. Resident 1 was pulling Resident 2's hair, and another resident tried to separate them. During a review of Resident 1's SBARs, the SBAR dated 9/01/2023 indicated a resident-to-resident altercation: the resident was arguing with another resident. Sitter began to approach to separate them. Sitter witnessed the other resident placed a nail on Resident 1's right forearm, resulting in a skin tear. The SBAR dated 9/05/2023 indicated a claimed allegedly resident to resident altercation: Resident 1 reported that an alleged altercation happened with another resident on 9/01/2023. During a review of Resident 1's nurses note dated 9/08/2023, the note indicated that staff called the doctor regarding the resident's multiple altercations with other residents, putting self and others in danger, threatening behavior, verbally aggressive and verbally abusive to staff, not redirectable, and an MD order to send the resident to the ER or psych (psychiatry, unit for residents with mental disorders). During a review of Resident 1's hospital discharge summary, dated 9/12/2023, the summary indicated that on 9/08/2023, Resident 1 was brought in due to the patient having repeated physical altercations with staff and other residents of the nursing home, with the last altercation resulting in superficial abrasions to the left jaw. Review of Resident 2's clinical record indicated she was admitted on 4/15/2021 and had diagnoses including hemiplegia (a condition that involves one-sided paralysis), bipolar disorder (a mental illness), major depressive disorder (a mood disorder that causes a feeling of sadness and loss of interest), and stimulant dependence. Her MDS, dated 10/17/2023, indicated a BIMS score of 13 (intact cognition). During a review of Resident 2's SBAR dated 9/08/2023, the SBAR indicated an altercation with another resident: per the resident, Resident 1 said something that made her upset, Resident 1 grabbed her right side of the breast, and she grabbed Resident 1's hair and scratched Resident 1's left side of the face. During an interview on 11/08/2023 at 10:10 a.m. with Resident 2, she was lying in her bed, and her call device was observed within her reach. Resident 2 stated she remembered that day, and Resident 1 was crazy. Resident 2 was outside of the facility, she tried to leave Resident 1 away, but Resident 1 kept saying bad stuff, which was upsetting her. Resident 1 grabbed her breast, and she scratched Resident 1's face. Resident 2 stated that there was no staff with Resident 1. Resident 2 further stated she was upset, and her breast was hurting then. During an interview on 11/08/2023 at 10:40 a.m. with Licensed Vocational Nurse A (LVN A), she stated she was informed that Residents 1 and 2 were arguing outside of the facility on 9/08/2023. LVN A stated the residents were fighting when she went out to the residents, and staff separated the residents immediately. LVN A further stated that Resident 1 had a history of multiple altercations with other residents and was transferred to the ER for her uncontrollable behavior on 9/08/2023. During an interview and record review on 11/08/2023 at 3:40 p.m. with LVN B, she confirmed Resident 1's physician's order of a 1:1 sitter and the intervention of a verbal aggression care plan to provide a 1 on 1 sitter. LVN B also confirmed that Resident 1 had an altercation with Resident 2 on 9/08/2023. LVN B stated that a 1:1 sitter was ordered for Resident 1 regarding her multiple altercations with other residents. LVN B further stated she could not locate any documentation indicating a 1:1 sitter was with Resident 1 when Resident 1 had the altercation with Resident 2 on 9/08/2023. During an interview and record review on 12/08/2023 at 1:30 p.m. with LVN A, she stated she could not locate any documentation indicating a 1:1 sitter for Resident 1 was provided as ordered. LVN A provided the facility's handwritten 1:1 sitter schedule for Resident 1. The schedule indicated that a 1:1 sitter was not provided on 8/22/2023; 8/23/2023; night shift on 8/24/2023; evening and night shift on 8/26/2023 and 8/28/2023; night shift on 8/29/2023, 8/30/2023, 8/31/2023, 9/01/2023, 9/02/2023, 9/03/2023, and 9/04/2023. LVN A confirmed the schedule review and stated the facility did not provide a 1:1 sitter as ordered. During a phone interview on 12/14/2023 at 12:30 p.m. with LVN C, she stated that she was the charge nurse for Resident 1 on 9/08/2023. LVN C stated the 1:1 sitter for Resident 1 came into the facility, and Resident 1 was alone outside of the facility during the altercation. LVN C confirmed that the 1:1 sitter to Resident 1 was not provided during the altercation. LVN C stated that the 1:1 sitter for Resident 1 should not have left the resident alone. During a phone interview on 1/19/2024 at 2:10 p.m. with Certified Nursing Assistant D (CNA D), she stated that she was the assigned 1:1 sitter for Resident 1 on 9/08/2023 during the day shift from 7:00 a.m. to 3:00 p.m. CNA D also stated, before the altercation happened, she saw Resident 1 give her ATM card to a male friend. CNA D went inside the facility to report it to her charge nurse and left Resident 1 alone outside of the facility. CNA D further stated when she and LVN C went outside the facility where she left Resident 1, both she and LVN C witnessed Residents 1 and 2 physically fighting. CNA D confirmed that Resident 1 stayed outside of the facility without any staff during the altercation. CNA D acknowledged that she should have stayed with Resident 1 while providing 1:1 sitter care. During a review of the facility's undated policy and procedure (P&P) titled "Abuse, Neglect and Exploitation Prohibition," the P&P indicated, "Each resident had the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property." During a review of the facility's undated policy and procedure (P&P) titled "Safety Supervision of Residents," the P&P indicated, "The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment." During a review of the facility's undated policy and procedure (P&P) titled "Comprehensive Plan of Care," the P&P indicated, "The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. The comprehensive plan of care must include interventions to prevent avoidable decline in function or functional level." The facility failed to ensure residents were free from verbal and physical abuse for two of three residents (Residents 1 and 2) when: 1. Resident 1 sustained facial injuries when Resident 2 scratched her in the face and was transferred to the emergency room (ER). 2. Resident 2 sustained emotional distress by feeling upset when Resident 1 said bad words, and complained of pain on her breast when Resident 1 grabbed her breast that resulted to minor physical injuries and emotional distress. This failure had direct relationship or immediate relationship to the health, safety, and security of the resident.