Health inspection·September 6, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported incident (FRI) CA00911909. Representing the Department, HFEN 39111. State Citation B was written. 42 C.F.R. § 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. 22 CCR § 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. 22 CCR § 72311. Nursing Service-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. On 8/1/24 at 9:55 A.M., an unannounced onsite visit was conducted related to an allegation of staff-to-resident physical abuse. It was determined the facility failed to ensure: 1. Resident 1, who was cognitively impaired and dependent on staff for care, was free from verbal and physical abuse when certified nursing assistant (CNA) 2 called the resident an "ass" then smacked the side of his head with an open hand while telling the resident, "That's for hitting me last week." 2. The facility's policy on Abuse: Prevention of and Prohibition Against was implemented. As a result, Resident 1 became agitated and attempted to hit staff back. In addition, Resident 1 had seemed "guarded" following the incident, per staff interview. This deficient practice had the potential to cause Resident 1 and other residents under CNA 2's care to experience fear, humiliation, and emotional distress. Findings: A review of Resident 1's Admission Record, dated 7/26/24, indicated the resident was admitted to the facility on 1/29/20 with diagnoses to include Parkinsonism (condition characterized by balance issues and tremors), unspecified psychosis (thoughts not based in reality), and dementia (condition characterized by impaired memory and judgement) with behavioral disturbance. A review of Resident 1's annual History and Physical, dated 4/10/24 indicated, the resident, "Does not have the capacity to understand and make decisions." A review of the facility's policy titled Abuse: Prevention of and Prohibition Against, dated 11/2017, indicated, "It is the policy of this facility that each resident has the right to be free from abuse... exploitation and mistreatment...." The policy defined abuse as "...willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish...Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish... Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm... Mental abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation... Mistreatment means inappropriate treatment... of a resident... Physical abuse includes but is not limited to hitting, slapping... Verbal abuse includes the use of oral...language that willfully includes disparaging and derogatory terms to residents... regardless of their age, ability to comprehend, or disability...." On 7/26/24, the Department received a report from the facility. The facility's document indicated, the facility was reporting an incident of suspected physical abuse perpetuated by CNA 2 against Resident 1 and that the incident had been witnessed by a student certified nursing assistant (SCNA). On 7/30/24 at 10:29 A.M., a telephone interview was conducted with SCNA. SCNA stated on 7/26/24 she went to help CNA 2 and CNA 3 give Resident 1 a shower. SCNA stated she, along with CNA 2 and CNA 3, were inside the shower room with Resident 1. SCNA stated they transferred Resident 1 from his wheelchair into the shower chair. SCNA stated Resident 1 was calm and cooperative at that time. SCNA stated CNA 2 was not talking nicely about the resident and had told her Resident 1 always fights and tries to hit staff and, "He's an ass." SCNA stated CNA 2 then "smacked" Resident 1 with an open hand on the side of his head while stating, "That's for hitting me last week." SCNA stated Resident 1 became agitated, had an angry expression on his face, and raised both hands in a motion to hit CNA 3 who stood directly in front of him. SCNA stated CNA 2 had been standing off to the side and was not standing in the resident's line of sight. SCNA stated CNA 2 left the shower room and that she remained behind with CNA 3 to help shower the resident. SCNA stated CNA 3 had to calm Resident 1 back down by rubbing his back. SCNA stated, "It didn't feel right... [CNA 2] wasn't treating [Resident 1] like a human..." SCNA stated what she saw was "abusive." SCNA stated Resident 1, "Seemed too confused to report such an incident himself." SCNA stated she reported the incident immediately to her CNA instructor. On 8/1/24 at 9:55 A.M., an onsite visit and interview with the Administrator (ADM) was conducted to investigate the facility reported allegation of abuse. The ADM stated she had finished her investigation of the 7/26/24 incident with Resident 1 and CNA 2 and provided a copy of the results of the investigation. The ADM stated she had substantiated SCNA's report of the incident, and CNA 2 had acted inappropriately. The ADM stated CNA 2 had been terminated and CNA 3 had also been terminated for failing to come forward about what occurred with Resident 1 on 7/26/24. The ADM stated CNA 2 had been hit by Resident 1 a couple of weeks ago and a facility incident report for work-related injuries was filed. A review of the facility's document titled [facility name] Confidential Abuse Investigation dated 7/30/24, and completed by the director of staff development (DSD) and ADM, indicated, "...Interviews...[SCNA] was advised [by CNA 2] to be careful as [Resident 1] tends to be combative and hit staff during care... [CNA 2] tapped the side of [Resident 1's] head and said, 'That's for punching me.' ... [CNA 2] denied tapping [Resident 1] on the head or making the comment...Findings: Although [CNA 2's] alleged actions likely stemmed from immaturity without intent to harm, the action is demeaning towards an elderly resident who lacks the capacity to make decisions and is not representative of [Facility]. [CNA 2's] employment with [facility] has been terminated. In addition, after much thought and consideration, decision was made to terminate [CNA 3] as well...." On 8/1/24 at 10:43 A.M., a telephone call was placed to CNA 3. CNA 3 did not respond or return the phone call. On 8/1/24 at 11:40 A.M., a joint interview and record review was conducted with the DSD. The DSD stated she conducted the facility's abuse prevention and dementia training. The DSD provided CNA 2 and CNA 3's training records for review and stated they were both trained on abuse prevention and dementia care. The DSD stated her staff training had included scenarios of joking around or horseplay and tapping or smacking a resident as not acceptable or appropriate behavior and such things were considered abuse. The DSD stated based on the abuse training provided by the facility, CNA 2 would have known her behavior was wrong. The DSD stated she interviewed CNA 3 about what had happened during Resident 1's shower and CNA 3 had put her head down and claimed to have not seen or heard anything on 7/26/24 during Resident 1's shower. The DSD stated this was not believable and, "There's no way she didn't hear or see what happened." The DSD stated CNA 3's employment had been terminated because she would not tell the truth about what had happened. The DSD stated CNA 2 and CNA 3 were, "Really good friends." The DSD reviewed the facility document titled Employee Incident Report dated 7/8/24, for CNA 2, which indicated, "...I [CNA 2] was taking [Resident 1's] brief off. While I was bent over [Resident 1] closed fisted, punched me in my face right side under eye...." The document listed CNA 3 and CNA 4 as a witness to the incident. The DSD further stated the SCNA started clinical training at the facility on 7/23/24 and would not have had knowledge of CNA 2 being hit in the eye by Resident 1 on 7/8/24 unless that was indeed what CNA 2 had said in the shower room on 7/26/24. On 8/1/24 at 12:14 P.M., an interview was conducted with CNA 4. CNA 4 stated Resident 1 was "very confused" and would sometimes try to hit or kick when he was touched during care. CNA 4 stated she had not been hit by the resident because she "dodged it," or would attempt care later if the resident was agitated. CNA 4 stated she did not take Resident 1's behavior personally, because he did not understand what he was doing. CNA 4 stated on 7/8/24, she was helping CNA 2 and CNA 3 with Resident 1 when she heard a "smack sound" and CNA 2 said, "My eye." CNA 4 stated she did not see the physical contact but that CNA 2's eye had a red mark and CNA 2 had to put ice on it. CNA 4 further stated discussing a resident's behavior, even if they were confused, should be done privately and not in front of the resident. CNA 4 stated it was "never okay" to use improper language with a resident or to smack a resident's head. CNA 4 stated she received abuse prevention training at the facility and according to her training, calling a resident an "ass" and smacking them on the head would be considered physical and verbal abuse. CNA 4 stated a cognitively intact person would feel bad about being treated like that. On 8/1/24 at 12:46 P.M., an interview was conducted with CNA 5. CNA 5 stated she knew Resident 1 well and had provided care to him since his admission to the facility. CNA 5 stated she heard Resident 1 would hit staff, but she had not seen or experienced that from the resident. CNA 5 stated Resident 1 had memory issues and was confused. The reported incident on 7/26/24 was discussed with CNA 5. CNA 5 stated she believed in the moment things were taking place, Resident 1 would have been able to understand that he was being discussed and was called an "ass." CNA 5 stated Resident 1 would probably get agitated in that situation and start mumbling. CNA 5 stated Resident 1 was a military veteran and if he was smacked on the head, he could get "triggered" and would probably try to defend himself. CNA 5 became tearful and stated she was upset to have heard what had been reported to have happened to Resident 1 on 7/26/24 during care. CNA 5 stated when she worked on 7/29/24, after having had time off, Resident 1 seemed, "Guarded, hesitant to accept care, and more agitated than usual." CNA 5 further stated she had not been aware of the report that Resident 1 had been called an "ass" and smacked on the head a few days prior to returning to work. CNA 5 stated she had not understood at that time why Resident 1 had acted different on her first day back to work. CNA 5 wiped the tears from her eyes and stated, "This is abuse, picking on someone who can't defend themselves or report what happened." CNA 5 stated as a reasonable person, if she experienced what Resident 1 had, she would feel upset and want to defend herself, too. On 8/1/24 at 12:37 P.M., an observation was conducted of Resident 1 while inside the resident's room. Resident 1 was in bed with the blanket pulled up to his chin. Resident 1 had his eyes closed and did not respond to interview attempt. Resident did not have any observable facial/head injuries. On 8/1/24 at 1:19 P.M., an interview was conducted with licensed nurse (LN) 6. LN 6 stated Resident 1 was severely cognitively impaired and depended on staff to provide care. LN 6 stated Resident 1 could not walk and that it took two to three staff to safely move him between locations. LN 6 stated she heard Resident 1 could hit staff, but she had not seen it or experienced it herself. LN 6 stated she was off on 7/26/24. What was reported to have occurred on 7/26/24 between Resident 1 and CNA 2, was discussed with LN 6. LN 6 stated it was unacceptable to discuss a resident's behavior in front of the resident, even if they were confused. LN 6 stated the facility had provided training related to abuse. LN 6 stated based on her facility training, being called an "ass" and smacked on the head was physical and emotional abuse. LN 6 further stated it was abuse even if the resident was confused, not hit hard, or the staff thought it was a joke. LN 6 stated Resident 1 was vulnerable and was not capable of telling anyone what had occurred on 7/26/24. LN 6 stated if what happened to Resident 1 had happened to her, she would feel, "Hurt, upset, and emotionally distressed." On 8/1/24 at 2:05 P.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 1 was cognitively impaired, had poor recall, and responded in a non-verbal way with mumbling that could not be understood. The ADON stated she was aware of the reported incident on 7/26/24 with CNA 2 and Resident 1. The ADON stated she had received facility training related to abuse. The ADON stated based on her training, what had occurred to Resident 1 was abuse. The ADON stated it was still considered abuse even though Resident 1 was confused and had memory issues. The ADON stated if it had happened to her, "I'd feel bad." On 8/1/24 at 2:45 P.M., a telephone interview was conducted with CNA 2. CNA 2 stated she helped CNA 3 transfer Resident 1 from his wheelchair into the shower chair while in the shower room on 7/26/24. CNA 2 stated she had been assigned two student CNAs to follow her that day and she had not worked with them before. CNA 2 stated she had asked one of them if she wanted to observe the resident's shower care. CNA 2 stated Resident 1 had been agitated, grabbed onto the shower handrail, and would not let go, and had been trying to bite CNA 3. CNA 2 stated she told the student that Resident 1 was combative and to watch out because he hits. CNA 2 stated that was all that she said about Resident 1. CNA 2 was asked if the resident's behavior should have been discussed in front of the resident. CNA 2 stated, "It should be done privately but [Resident 1's] AOx1 [only had awareness to self] and can't understand so I thought it was a good time to tell her [SCNA]." CNA 2 stated she pushed Resident 1's shoulders back when he tried to bite CNA 3 but did not touch the resident anywhere else. CNA 2 denied smacking Resident 1's head or calling the resident an "ass." CNA 2 was asked how the student CNA would have known that she had been hit by Resident 1 previously. CNA 2 stated, "Oh, well, I told her that he [Resident 1] punched me then, too." On 8/2/24 at 1:15 P.M., an interview was conducted with the Administrator (ADM). The Director of Nursing was also present. The ADM was asked if what happened to Resident 1 on 7/26/24 was abuse. The ADM stated the incident on 7/26/24 between Resident 1 and CNA 2 was an inappropriate interaction that she attributed to CNA 2's age and immaturity. The ADM stated the incident was substantiated and CNA 2 and CNA 3's employment had been terminated as a result. In violation of the above cited standards, the facility failed to ensure: 1. Resident 1, who was cognitively impaired and dependent on staff for care, was free from verbal and physical abuse when CNA 2 called the resident an "ass" then smacked the side of his head with an open hand while telling the resident, "That's for hitting me last week." 2. The facility's policy on Abuse: Prevention of and Prohibition Against was implemented. As a result, Resident 1 became agitated and attempted to hit staff back. In addition, Resident 1 had seemed "guarded" following the incident, per staff interview. This deficient practice had the potential to cause Resident 1 to experience fear, humiliation, and emotional distress. This violation threatened the patients' safety, health, and psychological well-being.