Health inspection·November 14, 2024

The Villas at Poway CA00916996 Event ID P5XD11 F600 Citation A The following reflects the findings of the California Department of Public Health (CDPH) during the investigation of: Entity Reported Incident (ERI) #: CA00916996 Event ID: P5XD11 State Citation A was written. 42 CFR §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. 22 CCR § 72311. Nursing Service (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 § 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. 22 CCR § 72527 (a)(10) Patients' Rights. (a) Patients 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. Patients shall have the right: (10) To be free from mental and physical abuse. On 9/4/24, an unannounced visit was made to the facility to investigate reported incidents of abuse to facility resident (Resident 7) that were recorded on videos. After investigation, CDPH determined the facility failed to: 1) Ensure Resident 7's freedom from abuse. As a result, Resident 7 was abused by two staff members, including but not limited to staff slapping, hitting, pulling, and pushing Resident 7. 2) Implement Resident 7's patient care plan, including but not limited to providing care with gentle touch and soft reassuring voice. 3) Follow facility's own abuse prohibition policy and procedure as further described below. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. A review of Resident 7's clinical record was conducted. Resident 7 was admitted to the facility on 3/11/22 according to Resident 7's face sheet. Resident 7's "Physician Progress Note," dated 8/8/24 indicated that Resident 7 had a diagnosis that included senile dementia (a progressive decline leading to loss of memory, language, problem solving, other thinking abilities and loss of independence in daily activities). Resident 7's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/31/24, section C0700 through section C1000, indicated that Resident 7 had short and long-term memory problem, memory/recall problem and severely impaired daily decision making. Resident 7's care plan for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) indicated "...LTC [Long-term Care] ADL Function Rehab...Last Updated on 2/22/24...Interventions...Provide Assistance to Support Level of Need...Assist With Oral Care/Grooming...Assist With Toileting/Peri Care...Assist With Dressing in Appropriate Clothes...Assist With Bathing to include Shower per Schedule..." Resident 7's care plan for behavior indicated "...LTC Behavioral Symptoms...Last Updated 9/30/22...Interventions...Provide Care With Smile, Gentle Touch, Soft Reassuring Voice..." A review of the facility's policy and procedure (P&P) titled, "Abuse Prohibition - Alleged," revised on 10/22/22 was conducted. The P&P indicated, "...to protect residents as dependent adults from abuse, neglect, involuntary seclusion, and misappropriation of property for all residents...Physical abuse includes...Assault, battery... Assault with... force likely to produce great bodily injury...Psychological/mental abuse includes fear, agitation...and other forms of serious emotional distress ... If a photograph or recordin [sic] of a resident... that it is used demeans or humiliates a resident (s)... regardless of the residents [sic] cognitive status will be considered abuse..." On 9/4/24 at 12:07 P.M., an interview was conducted with the Director of Nursing (DON), with the Administrator present, in the facility's conference room. The DON stated that on 1/26/24, she and the Administrator received a video call from an attorney who represented Resident 7's family. The DON stated that the attorney informed the DON and the Administrator that Resident 7's family placed a hidden camera in Resident 7's room from 11/29/23 through 1/26/24, which showed assaultive behavior by staff, evidence of shoving and hitting Resident 7, and lack of compassion by staff. The DON stated that she ended the call and directed the issue to the facility's "risk management" (department; the facility's process of identifying and controlling threats to an organization). The DON stated that on 8/22/24, she was notified by the [health care system's] Chief Nursing Officer (CNO) of videos that involved Resident 7. The DON stated she first viewed the video footage on 8/22/24. The DON stated that she and the Administrator identified two CNAs (CNA 1 and CNA 2) in the video footage. The DON stated that in one video, a third staff member was observing (the abusive behavior toward Resident 7) in the room. The DON stated she was able to identify the third staff member as licensed nurse (LN) 3 and confirmed all three staff members were employed by the facility in November 2023. On 9/4/24, CNA 1, CNA 2, and LN 3 were not interviewed. CNA 1, CNA 2, and LN 3 were no longer employed at the facility. A review of the videos from Resident 7's room was conducted on 9/25/24 at 8:56 A.M. in the facility's conference room with the Administrator. The Administrator provided a laptop computer to view the 11 recorded videos. The 11 videos were not identified with a date and/or time that indicated when the videos of the abuse incidents were taken/recorded. The Administrator identified CNA 1, CNA 2, and LN 3 in the videos. The undated video number one showed Resident 7 lying in bed wearing only a bra. Resident 7 was speaking in Spanish (unable to understand what the resident was saying in the video), and CNA 1 placed her right hand over Resident 7's mouth and told Resident 7, "Shh." CNA 1 then turned/positioned Resident 7 on the right side in a rough manner, pulled out Resident 7's brief from underneath Resident 7, wiped Resident 7's perineum (peri; area of skin between the anus and genitals; private area between the thighs), then turned Resident 7 in a rough manner on to the left side after putting a new brief on Resident 7. Resident 7 was frowning and was communicating to CNA 1 in Spanish (unable to determine what the resident was saying), but CNA 1 was not responding. Video number one lasted one minute. The undated video number two showed Resident 7 lying in bed. CNA 1 was standing near Resident 7's left side with a vital sign machine (machine that takes temperature, heart rate, blood pressure and oxygen saturation [oxygen level]). The blood pressure cuff was fastened on Resident 7's left upper arm. CNA 1 placed a thermometer under Resident 7's left underarm and the pulse oximeter (device to take oxygen level) on Resident 7's left finger. Resident 7 moved her left arm and CNA 1 held Resident 7's left arm down and tapped (to strike lightly, usually repeatedly) Resident 7's right side of face with CNA 1's right hand. CNA 1 told Resident 7, "Calmate [calm down], do not move," while holding the resident's left arm down, "Calmate, I told you." Video number two lasted two minutes and 47 seconds. The undated video number three showed Resident 7 lying in bed and CNA 1 was putting a shirt on Resident 7. CNA 1 placed Resident 7's left arm through the sleeve, then resident's head. While Resident7's head was up, CNA 1 hit Resident 7 with an open hand, at the back of Resident 7's head with her right hand. Video number three lasted 22 seconds. The undated video number four showed Resident 7 lying in bed. CNA 1 was standing near Resident 7's left side. CNA 1 took a pillow and a doll from Resident 7's right side and threw the pillow and doll on to the overbed table next to the right side of the bed. CNA 1 pulled down the white top sheet, exposed Resident 7's legs, took the pillow from Resident 7's right side, and hit resident on the face with the pillow. CNA 1 then threw the pillow at the foot of the bed. Resident 7 spoke to CNA 1 in Spanish (unable to determine what the resident was saying) and pulled the bottom of her hospital gown and covered her face. CNA 1 took the pillow from under Resident 7's head and threw it at the foot of the bed. Video number four lasted 41 seconds. The undated video number five showed Resident 7 sitting in a wheelchair positioned at the left side of the bed, facing the head of the bed. CNA 1 stood in front of Resident 7 and lifted Resident 7 to a standing position by holding on to Resident 7's left arm. Resident 7 wore a long sleeve shirt and a brief. As CNA 1 lifted Resident 7 off from the wheelchair and almost to a sitting position on the bed, CNA 1 unfastened the tape on the left side of Resident 7's brief. CNA 1 sat resident on the bed, then hit Resident 7 with an open hand on the back of the head with her right hand and placed both hands on Resident 7's head. CNA 1 forcefully pushed Resident 7's head down to lay on Resident 7's left side in bed. Resident 7 was frowning and speaking (unable to determine what the resident was saying) in Spanish. Video number five lasted 26 seconds. The undated video number six showed Resident 7 lying in bed exposed, wearing a long sleeve shirt and brief. CNA 1 was standing at the left side of the bed. CNA 1 pulled off Resident 7's blanket and the pillow from Resident 7's right side and threw the pillow toward the foot of the bed. Resident 7 grabbed a hospital gown, which was on the right side of bed, and CNA 1 grabbed it from Resident 7 and threw it on the floor. CNA 1 raised the height of the bed, pulled the pillow from Resident 7's left side, and threw it on the overbed table on the right side of bed. CNA 1 unfastened Resident 7's brief and stated to resident, "Open your legs." Resident 7 was saying something in Spanish (unable to determine what the resident was saying) and tried to hold on to her brief with her right hand. CNA 1 slapped (contact with an open hand) Resident 7's right hand that was holding on to the brief. Resident 7 was speaking in Spanish (unable to determine what the resident was saying), frowning, and crying. Video number six lasted 40 seconds. The undated video number seven showed Resident 7 lying in bed wearing only a brief. CNA 1 was changing Resident 7's brief and was positioned standing at the left side of the bed. CNA 1 walked to the right side of the bed and pushed Resident 7 on the hip to turn the resident on to the left side. Resident 7 held on to the left bedrail and CNA 1 pushed Resident 7's legs, which caused Resident 7 to sit up halfway, at the edge of the bed. CNA 1 pushed on resident's right shoulder as she pulled off a gray gown, then a blue gown from under Resident 7. CNA 1 grabbed Resident 7's right arm and pushed Resident 7 to lay back down in bed and pulled Resident 7's legs from a dangling position back to the center of the bed. CNA 1 threw the gowns on the floor and turned Resident 7's body on to the left side. CNA 1 wiped Resident 7's back and buttocks and removed the pad from under Resident 7 while pushing Resident 7's right leg. CNA 1 then pushed Resident 7's right leg again with CNA 1's right hand while CNA 1's left hand held on to Resident 7's right arm. CNA 1 slapped Resident 7's right upper thigh with her right hand. Video number seven lasted one minute. The undated video number eight showed Resident 7 lying in bed wearing a long sleeve shirt and purple pants that were pulled up to Resident 7's thigh. CNA 1 put pants on Resident 7, turned Resident 7 towards her, then grabbed and pulled Resident 7's long hair up to elevate Resident 7's head, and pulled Resident 7's hair and head towards her (CNA 1). LN 3 entered Resident 7's room and was talking (unable to determine what LN 3 was saying) to CNA 1. LN 3 was facing CNA 1 and Resident 7. The video showed LN 3's back and part of the left side of LN 3's face. As LN 3 was speaking with CNA 1 (unable to determine what LN 3 was saying), Resident 7's head was still being pulled with resident's head raised up to CNA 1's upper body. CNA 1 quickly lowered Resident 7's head and fixed (straightened/smoothed over) Resident 7's clothing. Resident 7 was frowning and speaking in Spanish during this video footage (unable to determine what the resident was saying). Video number eight lasted one minute. The undated video number nine showed Resident 7 lying in bed. CNA 1 walked to Resident 7's right side of the bed and pulled the pad under Resident 7 towards her. CNA 1 took a brief from the foot of the bed and walked to Resident 7's right side of the bed. Resident 7 sat up at the side of the bed and CNA 1 pushed Resident 7's head back down in bed, in a rough manner with CNA 1's left hand, then lifted Resident 7's legs from dangling at the edge of the bed and placed them in bed. Video number nine lasted one minute. The undated video number 10 included a title which indicated "Shaving cream" was applied to Resident 7. Video number 10 showed Resident 7 lying on her right side in bed, wearing no clothing. CNA 1 wiped Resident 7's back, back of thighs, and buttock with a white cream. CNA 1 opened a blue pad and a white pad, rolled the two pads together and placed the pads under Resident 7. Video number 10 lasted one minute. The undated video number 11 showed Resident 7 lying in bed turned on her left side towards CNA 2, who was standing next to the bed. CNA 2 changed the pad and brief from under Resident 7. Resident 7's right leg was crossed over the left leg and CNA 2 separated Resident 7's legs open in a forceful manner, pushed Resident 7's right leg with her (CNA 2) right hand to keep Resident 7's legs open. Resident 7 screamed out "Ahhhh" and was crying. Video number 11 lasted 39 seconds. During an interview on 9/25/24 at 10:12 A.M. with the DON, the DON acknowledged that Resident 7 was abused and stated that the videos were "devastating and shocking." The DON stated that Resident 7 "...looked terrified and experienced pain as it was heard on the video." After investigation, CDPH determined the facility failed to: 1) Ensure Resident 7's freedom from abuse. As a result, Resident 7 was abused by two staff members, including but not limited to staff slapping, hitting, pulling, and pushing Resident 7. 2) Implement Resident 7's patient care plan, including but not limited to providing care with gentle touch and soft reassuring voice. 3) Follow facility's own abuse prohibition policy and procedure as further described above. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.