Other·September 15, 2023

The following reflects the findings of the California Department of Public Health during the investigation of a Facility Reported Incident. Representing the Department: Health Facilities Evaluator Nurse 47984 State Citation B was written. § 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 8/4/23 at 8:25 A.M., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Resident 1 sustaining physical and verbal abuse from Resident 2. The facility failed to provide an environment that was free from abuse for Resident 1, when Resident 1 and Resident 2 were not permanently separated after Resident 2 threatened Resident 1. This failure resulted in Resident 2 slapping Resident 1 on the face on 7/30/23. An interview with the Director of Nursing (DON) was conducted on 8/4/2023 at 9:30 A.M. The DON stated Resident 2 slapped Resident 1 because Resident 2 was annoyed of Resident 1's singing. The DON stated that both residents were separated. The DON stated Resident 2 was out of the facility with family. A record review of Resident 1's facesheet indicated that Resident 1 was admitted to the facility on 3/8/2023 with diagnoses that included Dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident 2's facesheet indicated that Resident 2 was admitted to the facility on 7/27/2023 with diagnoses that included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and Dementia with Agitation (become restless, causing a need to move around or pace, or become upset in certain places or when focused on specific details). An observation of Resident 1 was conducted on 8/4/2023 at 10:00 A.M. Resident 1 was asleep in bed in a private room. An interview with licensed nurse (LN) 1 was conducted on 8/4/2023 at 10:05 A.M. LN 1 stated Resident 1 was transferred from Station 1 to Station 2, into a private room, after the incident on 7/30/23 with Resident 2. LN 1 stated Resident 1 did not have visible injuries. LN 1 stated that Resident 1 could verbalize her needs but was not interviewable. An interview with LN 2 was conducted on 8/4/2023 at 10:11 A.M. LN 2 stated she was informed by staff of the incident between Resident 1 and Resident 2. LN 2 stated Resident 1 and Resident 2 were roommates. LN 2 stated Resident 2 slapped Resident 1 because Resident 1 was singing. LN 2 stated, when certified nursing assistant (CNA) 2 entered the room, CNA 2 saw that Resident 2 was on top of Resident 1. LN 2 stated CNA 2 separated both residents. LN 2 stated both residents were assessed for injuries, and none were observed. LN 2 stated Resident 1 was moved to a different room first due to Resident 2's aggressiveness. A telephone interview with CNA 2 was conducted on 8/4/2023 at 1:29 P.M. CNA 2 stated that the night before the incident (7/29/2023), Resident 2 threatened Resident 1 of being slapped if Resident 1 did not stop making noises. CNA 2 stated Resident 2 made noises to communicate her needs, especially when she (Resident 1) was soiled. CNA 2 stated she was concerned about the threats made by Resident 2 towards Resident 1 and reported the incident to LN 3. CNA 2 stated that LN 3 did not do anything so she (CNA 2) transferred Resident 1 in a G-chair and placed the G-chair in the hallway until she could find an empty room to put Resident 1 in. CNA 2 stated she reported the incident to the incoming shift CNA. CNA 2 stated she was surprised to find Resident 1 back in the same room with Resident 2 the following night. CNA 2 stated that night, while she was assisting Resident 1, Resident 2 threatened Resident 1 and said, "Shut up, shut up, if you don't shut up, I'm going to slap you". CNA 2 stated she decided to sit outside of both residents' room. CNA 2 stated that at around 2:00 A.M., she (CNA 2) heard Resident 2 say, "I'm going to slap you across the face", then heard the curtain open. CNA 2 stated she went inside the residents' room, turned on the light, and saw Resident 2 standing by Resident 1's bed and slapped Resident 1 with the back of her left-hand. CNA 2 stated she intervened, and that Resident 2 was really upset, and had mixed emotions of being angry, sad, remorseful. CNA 2 stated CNA 3 came and helped moved Resident 1 to another room. A telephone interview with LN 3 was conducted on 8/4/2023 at 1:55 P.M. LN 3 stated that CNA 2 came to him to let him know that Resident 2 hit Resident 1. LN 3 went to Resident 1 and Resident 2's room and saw Resident 1 was asleep in bed. LN 3 stated he assessed Resident 1's skin and face and found no visible injuries. LN 3 stated he saw Resident 2 sitting by her bed rolling her clothes. LN 3 stated he attempted to interview Resident 2, but Resident 2 only talked to herself and provided no response. LN 3 did not recall working the night before the incident. LN 3 stated it was his first time to care for Resident 1 and 2 on 7/30/23. A review of the facility's attendance sheet for 7/29/23 and 7/30/23 night shift for Station 1 indicated that LN 3 worked on the night before the incident (7/29/23) and the night of the incident (7/30/23). A telephone interview with the Assistant Director of Nursing (ADON) was conducted on 8/4/2023 at 2:57 P.M. The ADON stated that she spoke to CNA 2 the day after the incident. The ADON stated CNA 2 informed her that CNA 2 observed Resident 1 get slapped by Resident 2. The ADON stated CNA 2 told her that earlier that night, Resident 1 was making noises and Resident 2 was yelling at Resident 1 to shut up. The ADON stated CNA 2 stayed outside the door to monitor the behavior. The ADON stated she completed her investigation on the 31st and reported the incident to the Department. The ADON stated abuse occurred being that the incident was witnessed by a staff. A telephone interview with CNA 5 was conducted on 8/7/2023 at 3:07 P.M. CNA 5 confirmed that she worked with CNA 2 the night before the incident occurred between Resident 1 and Resident 2 (7/29/23). CNA 5 stated CNA 2 called her to assist with changing Resident 1's incontinent briefs. CNA 5 stated Resident 1 kept making noises and Resident 2 would tell Resident 1 to shut up. CNA 5 stated that she and CNA 2 tried to explain to Resident 2 what they were doing and why Resident 1 was making noises, but Resident 2 kept saying "shut up, shut up". CNA 5 stated CNA 2 reported Resident 2's behavioral concerns to LN 3. An interview with the DON was conducted on 8/8/2023 at 10:10 A.M. The DON stated both Resident 1 and Resident 2 should have been separated the night before the incident, when Resident 2's behavioral concern was first reported by CNA 2. The DON acknowledged that abuse could have been prevented if Resident 1 and Resident 2 were separated. A review of the facility's policy and procedure titled. "Resident Rights", revised on December 2016, the P&P indicated under "Policy Interpretation and Implementation...1.- Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: ...b.- be treated with respect, kindness, and dignity; c.- be free from abuse...." The facility failed to provide an environment that was free from abuse for Resident 1, when Resident 1 and Resident 2 were not permanently separated after Resident 2 threatened Resident 1. This failure resulted in Resident 2 slapping Resident 1 on the face. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient.