Health inspection·April 22, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported Incident (FRI) CA00885596 Representing the Department, HFEN 39111 and 49330. 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 an individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22 CCR § 72523. 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 2/22/24 at 8:30 A.M., an unannounced visit was conducted at the facility to investigate an allegation of resident-to-resident physical abuse. It was determined that the facility failed to ensure: 1. Resident 2 was free from physical abuse when Resident 1, who had a history of hearing voices and responding with physical aggression, punched Resident 2 in the eye. 2. Further incidents of physical aggression were prevented when Resident 1 was removed from 1:1 supervision (continuous supervision provided by an assigned staff member) and placed on q15 (every 15 minutes) location monitoring which the facility had previously determined was ineffective in managing the resident's aggressive behavior. 3. Its policy and procedure titled "Abuse Prevention Program" was implemented. As a result of these failures, Resident 2 sustained a bruise to the right eye and was sent to the hospital for evaluation. This had the potential for Resident 2 to experience pain, psychosocial distress, and trauma. In addition, this placed other residents on the unit at risk for physical abuse. Findings: A review of Resident 2's Admission Record indicated the resident was admitted to the facility on 8/24/23 and re-admitted on 2/20/24. A review of Resident 2's Emergency Room documentation dated 2/17/24, indicated, "...[Resident 2] presents today via EMS [Emergency Medical Services] brought in from [facility name] status post altercation with another patient approx-1 hour prior to evaluation in the emergency department. Patient reports that he was punched in the right side of his face. Reportedly fell...patient currently endorsing headache...constant since the altercation. Claims associated blurred vision and dizziness...." A review of Resident 2's readmission assessment dated 2/20/24 and signed by the licensed nurse on 2/21/24, indicated, "...Ecchymosis [bruising]/yellowish brown in color/healing around right eye socket...." A review of Resident 1's Admission Record indicated the resident was admitted on 4/12/23 and re-admitted to the facility on 1/29/24 with diagnoses including schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood), and impulse disorder (a condition that makes it difficult to control actions or reactions). A review of Resident 1's Psychiatry Progress note, dated 6/19/23, indicated the resident had auditory hallucinations (hearing things that are not there) and "he continues to endorse voices, grandiose delusions [false beliefs], and violent impulses." A review of Resident 1's nursing progress notes indicated: · 5/14/23 at 5:35 P.M. - Resident 1 "came into the dining room and hit the female resident with a full lotion container, hit the female resident in the L [left] side of the face..." Resident 1 was heard "swearing/posturing screaming/yelling and said 'how do you like it [expletive]?" · 6/10/23 at 3:07 P.M. - Resident 1 "threw water at two different CNA [certified nurse assistant] staff and half cup of water at LN [licensed nurse]. Resident [Resident 1] stated he is hearing voices...Resident [Resident 1] then later went into the hallway and attempted to throw a bottle of lotion at peer, but hit CNA's thigh." · 6/12/23 at 10:47 P.M. - Resident 1 was on "monitoring q15" due to aggressive behavior towards peers. A review of Resident 1's Behavior note, dated 6/12/23 at 12:29 P.M., indicated Resident 1 threw water at a peer and "picked up a chair and hit peer with the chair." · 12/29/23 at 1:30 P.M. - Resident 1 "stuck [sic] peer in the hallway in face..." · 1/1/24 at 10:04 A.M.- Resident 1 stated "...The voices get really bad sometimes...." · 1/6/24 at 8:17 A.M. - Resident 1 "was involved in an incident in which he struck a peer." · 1/10/24 at 9:27 A.M. "... [Resident 1] stated that his voices were telling him to rape and kill people...." · 1/17/24 at 8:41 P.M. - "The resident continued expressing thoughts of harming others, stating 'the voices in my head are telling me to hurt you. They want me to rape.'" · 2/17/24 at 2:23 P.M. - "Writer heard a disturbance from down the hallway. [Resident 1] assaulted select peer [Resident 2] x 2 [twice] unprovoked...when conversating about why he did it he explained that the voices told him to do it." ·2/17/24 at 2:34 P.M.- Resident 1 was asked what had happened in the hallway and the resident responded "... 'I hit him' when asked why he stated 'they are telling me to kill (voices)'...." A review of Resident 1's interdisciplinary team (IDT- a group of healthcare professionals with various areas of expertise) note, dated 1/18/24 at 8:43 A.M., indicated Resident 1 "became agitated while responding to internal stimulation, resulting in him assaulting a peer" and "as of recent [Resident 1] has been involved in multiple instances in which [Resident 1] has acted in an aggressive manner, making assaultive physical contact with peers. All the noted incidents are related to his hallucinations, voices instructing him to harm others." The note further indicated, "the team has implemented various approaches; IE Q-15 checks [location monitoring] ...None of the above have been successful in altering assaultive behavior." Resident 1 was sent to an acute psychiatric hospital for further evaluation per the IDT note. A review of Resident 1's IDT note dated, 1/29/24, indicated that Resident 1 returned to the facility from a psychiatric hospital. Per the IDT note, the resident was calm upon returning from the psychiatric hospital, however "despite [Resident 1's] current disposition the potential for combative/assaultive behavior remain." 1:1 supervision was implemented as a new approach to ensure the safety of the residents. A review of Resident 1's IDT note, dated 2/14/24 at 12 P.M., indicated, "[Resident 1's] behavior has been stable, reports no longer hearing voices instructing him to harm self/others. Appropriately seeking out nursing staff to verbalize feelings. 1:1 supervision discontinued per IDT review and resident placed on q15 minute safety checks [location monitoring]...." A review of Resident 1's Psychologist Note dated 2/15/24, indicated, "...[Resident 1] was seen earlier in the day...[Resident 1] is demonstrating symptoms of distorted reality noted to be moderate to severe in intensity; delusions noted to be moderate in intensity and also hallucinations noted to be moderate in intensity. [Resident 1] evidences distorted reality including 1. tangential speech [wandering thoughts] 2. concrete reasoning 3. frequent misinterpretations 4. unusual thought content...delusional thinking patterns are evident including paranoid themes. Hallucinations are present including auditory...[Resident 1's] ability to communicate effectively is impacted as expected by their cognitive state and mental status...." On 2/22/24 at 11:40 A.M., an interview was conducted with CNA 2. CNA 2 stated she had provided 1:1 supervision for Resident 1. CNA 2 stated Resident 1 was "not getting in trouble on 1:1 [supervision]." CNA 2 stated Resident 1 did not consistently self-report when he felt angry or anxious. CNA 2 stated Resident 1 would disclose his feelings when asked and she would then take him to the nurse. CNA 2 stated this helped "prevent a lot of problems." CNA 2 stated "He [Resident 1] needs 1:1. It worked for him." On 2/22/24 at 12 P.M., an interview was conducted with the Program Counselor (PC). The PC stated that 1:1 supervision worked well for Resident 1. The PC stated that 1:1 supervision allowed Resident 1 to have a staff member present to talk to him during episodes of hearing voices and hallucinating. The PC further stated "1:1 monitoring kept others safe from Resident 1" and Resident 1 may not always self-report hearing voices if he is only on q15 monitoring. The PC stated that Resident 1 "is not 100% fine, he is fine until the voices get to him. He responds well when someone is right there." On 2/22/24 at 1:43 P.M., an interview was conducted with the Director of Nursing (DON). The administrator was also present. The DON stated, "He [Resident 1] is dangerous" and he consistently talks about killing people and raping children and that the voices tell him to do so. On 3/6/24 at 9:15 A.M., an interview with Resident 2 was conducted. Resident 2 stated [on 2/17/24] while walking down the hall in Cottage 2, Resident 1 told him to "eff off," unprovoked, and hit him on the outer corner of his right eye. Resident 2 stated he fell to his knees and had pain in his right eye. Resident 2 stated, "I thought he was going to kill me." On 3/6/24 at 12:55 P.M., an interview with CNA 1 was conducted. CNA 1 stated q15 monitoring meant "to see what residents are doing and where they are" and that they were only documenting the resident's location. CNA 1 stated that during a 1:1 supervision, Resident 1 was constantly reassured and reminded to report hearing voices. CNA 1 stated asking Resident 1 if he was alright would help more than just looking to see where he was at. CNA 1 stated that Resident 1's voices were "very active" and Resident 1 would tell her, "They're always telling me to do bad things." CNA 1 stated 1:1 supervision worked well for Resident 1 and asking him about the voices and how he was feeling was "very effective." On 3/6/24 at 1:40 P.M., an interview was conducted with LN 3. LN 3 stated 1:1 supervision worked well for Resident 1 and he had no incidents of aggression while on 1:1 because CNAs could talk to him about his feelings and bring him to the licensed nurse when agitated for a nursing assessment. On 3/6/24 at 1:50 P.M., an interview was conducted with LN 1 and LN 2. LN 1 stated that Resident 1 was managed on 1:1 supervision and had no incidences of assaulting others while on 1:1. LN 2 stated Resident 1 would ask for a PRN (as needed) medication and come to the nurse when hearing voices to hurt others. Both LN 1 and LN 2 stated Resident 1 did not consistently do that on his own "100% of the time." Both LN 1 and LN 2 stated Resident 1 responded well to 1:1 and should have stayed on 1:1 to prevent others from getting hurt. On 3/6/24 at 2:25 P.M., an interview was conducted with the Infection Prevention Nurse (IPN). The IPN stated he was working on 2/17/24 and witnessed Resident 1 hit Resident 2 in the face unprovoked. The IPN stated he was part of the IDT discussion on 1/18/24 and that q15 location monitoring had been determined to not be effective in managing Resident 1's behavior. The IPN stated q 15 location monitoring did not prevent Resident 2 from being hit. The IPN stated that Resident 2 had not been free from abuse. On 3/7/24 at 12:15 P.M., a joint record review and interview was conducted with the facility's Assistant Director of Nursing (ADON). A record review indicated Resident 1 did not have any incidences of physical or verbal aggression while on 1:1 supervision. The ADON stated that Resident 1 was placed on 1:1 supervision on 1/29/24 "to not put people at risk" from Resident 1's physical aggression. The ADON stated that q15 safety checks meant "putting eyes" on a resident and noting their location on the unit and "demeanor." The ADON stated the facility was not the "environment for 1:1 continuous" and that it was a facility protocol to downgrade 1:1 supervision to q15 location monitoring. The ADON stated Resident 1's behavior had been escalating in the last few months. The ADON stated that in order to protect others, Resident 1 should not have been "downgraded" to q15 location monitoring. The ADON stated sometimes Resident 1 told staff about wanting to hurt others and hearing voices when they were bothering him. The ADON stated there were times Resident 1 did not tell staff about the voices. The ADON stated Resident 1's ability to self-report wanting to hurt others and hearing voices was not reliable. The ADON stated when Resident 1 hit Resident 2 physical abuse had occurred. On 3/7/2024 at 12:50 P.M., an interview was conducted with the administrator (ADM) who stated Resident 2 was not free from physical abuse when Resident 1 hit him. The ADM further stated, "that's why we reported it." A review of the facility's policy titled Abuse Prevention Program effective 7/1/20 indicated, "Our residents have the right to be free from abuse...As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to...other residents..." In violation of the above cited standards, the facility failed to ensure: 1. Resident 2 was free from physical abuse when Resident 1, who had a history of hearing voices and responding with physical aggression, punched Resident 2 in the eye. 2. Further incidents of physical aggression were prevented when Resident 1 was removed from 1:1 supervision and placed on q15 location monitoring which the facility had previously determined was ineffective in managing the resident's aggressive behavior. 3. Its policy and procedure titled "Abuse Prevention Program" was implemented. As a result of these failures, Resident 2 sustained a bruise to the right eye and was sent to the hospital for evaluation. This had the potential for Resident 2 to experience pain, psychosocial distress, and trauma. In addition, this placed other residents on the unit at risk for physical abuse. This violation threatened the patients' safety, health, and psychosocial well-being.