Health inspection·August 4, 2022

The following reflects the findings of the California Department of Public Health during the investigation of: Two Entity Reported Incidents #729084 & #728691. Representing the Department, HFEN 42577 & HFEN 21052. State Citation B was written. Regulation: Title 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 3/15/21 an unannounced visit to the facility was conducted due to allegations of abuse reported by the facility. The facility reported to the Department, the first incident, involving Resident 1 on 3/11/21, and reported a second incident to the Department, which involved Resident 2 on 3/15/21. According to the facility report submitted to the Department, both allegations involved CNA 1. The facility failed to ensure Resident 1 and Resident 2 were free from abuse when: 1. Certified Nursing Assistant 1 (CNA 1) pushed Resident 1 hard and told the resident, "Why don't you god damn move", during care. 2. Certified Nursing Assistant 1 (CNA 1) punched and roughly handled Resident 2 during care. As a result, the incident caused both Resident 1 and Resident 2 to experience pain and feelings of anger. In addition, the incident brought back memories of child abuse for Resident 1. 1. A review of Resident 1's medical record was conducted. Resident 1 was re-admitted to the facility on 1/27/21 with diagnoses that included muscle weakness according to the facility's undated face sheet. The undated face sheet also indicated Resident 1 was her own responsible party. Resident 1's Minimum Data Set (MDS -assessment tool), 3/12/2021 indicated Resident 1 required extensive assistance with bed mobility and toileting. During an observation and interview on 3/15/21 at 1:18 P.M., Resident 1 was pleasant, alert and engaged with the interview. Resident 1 stated that she tried to turn on her left side where certified nursing assistant (CNA) 1 told her to turn. Resident 1 stated she must have been going too slow because CNA 1 pushed her "really hard". Resident 1 stated CNA 1 said to her "why don't you god damn move?" Resident 1 stated she told CNA 1 she was as far as she could go. Resident 1 stated CNA 1 then threw her right leg over her left leg and her right leg went off the bed. Resident 1 stated she told CNA 1 that she was going to fall out of the bed. Resident 1 stated CNA 1 did not respond to her concern and continued with her care. During an observation and interview on 3/17/21 at 10:20 A.M., Resident 1 stated the incident on 3/10/21 with CNA 1 made her feel "icky". Resident 1 was visibly upset; Resident 1 looked toward the ground and shook her head when discussing the incident with CNA 1. A review of Resident 1's medical record was conducted. A document titled, "Physicians Progress Notes" written by Psychiatrist 1, dated 3/10/21 indicated, "Pt (Resident 1) states that > [sic] was brought up not to be rude and she felt the staff was rude to her-this is especially bothersome to her because her dad used to be this way...perceives staff's action as abusive." During an observation and interview on 4/5/21 at 9 A.M., this writer discussed with Resident 1, the conversation she (Resident 1) had with Psychiatrist 1, on 3/10/21. Resident 1 stated she informed Psychiatrist 1 that CNA 1's action "was abusive". Resident 1 stated CNA 1's actions brought back memories of her dad hitting her when she did something wrong or used any swear words. Resident 1 stated when CNA 1 pushed her hard and spoke to her in the manner that she did, she (Resident 1) considered that physically and verbally abusive. Resident 1 stated she told the Director of Nursing (DON) that CNA 1 should not be working with any residents. During a telephone interview on 3/16/21 at 1:37 P.M., CNA 1 stated she did not recall the incident with Resident 1 that allegedly occurred on 3/10/21. CNA 1 stated Resident 1 was easy to care for and that she did not have any issues with Resident 1. CNA 1 stated Resident 1 required minimal assistance and that the resident was able to turn herself in bed. CNA 1 stated the only time she touched Resident 1 the morning of 3/10/21 was when she used peri-wipes to clean Resident 1's perineal area (area between the tail bone and the pubic arch) during the brief change. CNA 1 stated Resident 1 did all of the turning herself. A document review was conducted. Document titled "Abuse Prevention and Prohibition Program" dated January 30, 2020 indicated, "I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero- tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident's property. II. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitor. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing." During a telephone interview on 4/13/21 at 4:15 P.M., The Administrator (ADM) stated his intentions were to provide an environment free from abuse for all residents at the facility. The ADM stated "Yes" when asked if the facility ensured that Resident 1 was free from abuse. The ADM stated the facility had deficiencies and inconsistencies in their investigation of Resident 1's allegation but stated the facility could not take the responsibility that it caused the abuse. The ADM stated he believed Resident 1's perception of the incident was accurate. The ADM stated all residents at the facility should be free from abuse because that was the "human" thing to do. The ADM stated the facility should protect all residents. 2. A review of Resident 2's medical record was conducted. Resident 2 was readmitted to the facility on 2/9/21 with diagnoses that included cerebral infarction (brain damage due to lack of blood supply) affecting right dominant side (right side of the body), and generalized muscle weakness according to the facility's undated face sheet. Resident 2's face sheet also indicated the resident's daughter was the resident's responsible party. Resident 2's Minimum Date Set (MDS - assessment tool), dated 3/29/21, indicated Resident 2 required one-person physical assist with bed mobility and toileting. During an observation and interview on 3/17/21 at 11:05 A.M., a pad of paper was used during the interview to communicate with Resident 2 due to her hearing loss. Resident 2 stated she was asleep and was woken up when CNA 1 rolled her over, using the cloth pad under her, and pulled her legs up hard. Resident 2 stated CNA 1 did not announce herself or explain what she was going to do to her. Resident 2 stated she told CNA 1 she was in pain. Resident 2 stated CNA 1 proceeded to roll her onto her other side to change her brief, then CNA 1 hit her on the left shoulder with a "punch". Resident 2 closed her fist and demonstrated the punch with this writer's own arm, and said CNA 1's punch was harder, while the resident grimaced her face. Resident 2 stated she told CNA 1 to leave her alone or she would tell the supervisor. Resident 2 stated, "It made me mad." Resident 2 stated, "If I had the strength I would have fought back and hit the CNA to protect myself." Resident 2 stated CNA 1 also punched her twice in the center of her back during the same brief change. During a telephone interview on 3/16/21 at 10:45 A.M., Resident 2's Responsible Party (RP) stated when she asked Resident 2 about the incident, Resident 2 told her that she was punched in the back twice by CNA 1 using her fist and that CNA 1 also punched her in the left shoulder. RP stated Resident 2 demonstrated what happened to her by putting her hand in a fist and hit the palm of her other hand with force to show how CNA 1 punched her. RP stated Resident 2 told her that she asked CNA 1 what she was doing, and CNA 1 did not answer. The RP stated Resident 2 had been at the facility for 1 year and had never once complained about care or mistreatment. The RP stated, "That is why I know something happened." A document review was conducted on 3/16/21 at 4:23 P.M. The document titled "Initial interview done with (Resident 2's name) on 3/12/21 at approximately 8:40 am:" indicated, that Resident 2 reported to the facility, "that lady last night hurt me, I told her to stop and she didn't, it hurt bad, it hurt real bad." According to the document Resident 2 told CNA 1 "stop it, your [sic] hurting me". Per the report CNA 1 again lifted the resident's legs in the air and dropped Resident 2's legs on the bed. The document indicated Resident 2 yelled again "stop it" and that was when CNA 1 began to change Resident 2's brief. The document indicated CNA 1 turned Resident 2 on her side and punched her on the back. Per the document, Resident 2 grabbed CNA 1 and pushed her, and then CNA 1 went to the other side of Resident 2's bed and punched the resident again in the back. Per the document, Resident 2 pushed the call light to asked for pain medication, CNA 1 answered the call light and told Resident 1, "no and walked out." A document review was conducted. The document titled "Abuse Prevention and Prohibition Program" dated January 30, 2020, indicated, "I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero- tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident's property. II. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitor. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing." During a telephone interview on 4/13/21 at 4:15 P.M., The Administrator (ADM) stated his intentions were to provide an environment free from abuse for all residents at the facility. The ADM stated "Yes" when asked if the facility ensured that Resident 2 was free from abuse. The ADM stated the facility had deficiencies and inconsistencies in their investigation of Resident 2's allegation but stated the facility could not take the responsibility that it caused the abuse. The ADM stated he believed Resident 2's perception of the incident was accurate. The ADM stated all residents at the facility should be free from abuse because that was the "human" thing to do. The ADM stated the facility should protect all residents. The facility failed to ensure Resident 1 and Resident 2 were free from abuse which caused both Resident 1 and Resident 2 to experience pain and feelings of anger. In addition, the incident brought back memories of child abuse for Resident 1. These violations had a direct or immediate relationship to the health, safety, or security of patients or residents.