Health inspection·May 7, 2024

El Centro - 788349, EVENT ID: G40Z11 Class-A Citation Draft 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. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22 CCR § 72527 Patient's 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. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 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. 42 CFR §483.21 Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40. 22 CCR § 72311 Nursing Service - General (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessment shall commence at the time of admission of the patient and be completed within 7 days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. 22 CCR § 72523(a) 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. The Department conducted an unannounced visit on 6/9/22, to investigate a facility reported incident which occurred on 6/9/22.Based upon observation, interview and record review, facility's failure to adequately protect the resident (Resident 1) resulted in Resident 1 being sexually abused by another resident (Resident 2). The facility failed to: 1. Take measures to uphold Resident 1's right to be treated with dignity and respect in an environment free from the serious mental and physical harms of sexual abuse when a known wandering and cognitively impaired resident with a history of wandering into other residents' rooms (Resident 2) resided adjacent to Resident 1. 2. Develop a care plan for Resident 2 to prevent sexual abuse of facility residents per Resident 2's observed wandering the facility and into other resident's rooms and Resident 2's cognitive impairment diagnosis. More specifically, develop an accurate safety assessment of Resident 2's (an "aimless" movement from one place to another) behaviors, as well as, interdisciplinary and core staff communication for the planning, monitoring, and evaluating of Resident 2's plan of care related to his wandering behaviors, to ensure Resident 2 did not interfere with other resident's safety. 3. Follow facility policy and procedures, "Resident Rights", "Wandering", revised March 2019 indicated, "The facility will identify residents who are at risk for unsafe wandering and strive to prevent harm...1. If identified as at risk for wandering...or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety..." "Safety and Supervision of Residents", designed to protect residents from the type of serious harm suffered by Resident 1. Residents 1 & 2: Resident 1 was admitted to the facility on 3/14/22, from a general acute care hospital (GACH) for skilled nursing, with diagnoses which included stroke (a loss of blood flow to part of the brain, which damages brain tissue) and generalized muscle weakness, per the facility's Admission Record. Resident 1's History and Physical (H&P), dated 3/14/22, the H & P indicated the attending physician (AP 1) documented Resident 1 did not have the capacity to understand and make decisions. Resident 1's Minimum Data Set (MDS - an assessment tool), dated 3/16/22, the MDS indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 5 (point system that ranges from 0 to 15, 0 to 7 points suggests severe cognitive impairment, 8 to 12 points suggests moderate cognitive impairment, 13 to 15 points suggests that cognition is intact). The MDS section G for activities of daily living (ADLs- activities related to personal care...include...getting in and out of bed...) indicated, Resident 1 needed limited assistance and required a one-person physical assist during bed mobility. Resident 2 was admitted to the facility on 2/7/22, from a skilled nursing facility, with diagnoses which included dementia (the loss of cognitive functioning like thinking, remembering, and reasoning), per the facility's Admission Record. Resident 2's H&P, dated 2/7/22, indicated, the attending physician (AP 1) documented Resident 2 did not have the capacity to understand and make decisions. Resident 2's MDS dated 2/10/22, indicated, Resident 2's BIMS score was 6, which meant Resident 2's cognition was severely impaired. The Behavior section of the MDS dated 2/10/22 and 5/13/22, indicated Resident 2 did not have a wandering behavior. Description of Event: Resident 1's Change in Condition (CIC) notes, dated 6/9/22, at 3:09 A.M., completed by a Licensed Nurse (LN) 1, indicated on 6/9/22, Resident 1 was heard shouting from her room, Certified Nursing Assistant (CNA) 3 checked Resident 1, found Resident 2 in Resident 1's bed without underwear, and his hips propped against Resident 1's lower region. The LN CIC notes indicated, Resident 2 was in this position until CNA 3 showed up to witness, then Resident 2 released Resident 1 and pulled up his underwear. Resident 1's GACH record, dated 6/9/22 at 2:06 P.M., the Emergency Department Attending Physician (EDAP 1) documented Resident 1 presented to the emergency room for evaluation after sexual assault. Per EDAP 1 notes on 6/9/22 at 8:08 P.M., Resident 1 underwent diagnostic test which included Sexual Assault Response Team (SART, sexual assault forensic evidence exam - an examination designed to gather evidence of the sexual assault and provide healthcare services). While hospitalized, Resident 1 received prophylactic medications including antibiotics and antivirals. During a review of the medication list that were given to Resident 1 while she was at the GACH dated 6/9/22, the medication list indicated Resident 1 received two antiviral (Raltegravir and Emtricitabine-Tenofovir) oral medications, one oral antibiotic (Doxycycline), and two intramuscular (IM) antibiotics (Ceftriaxone, Penicillin G Benzathine). The same EDAP 1 note indicated, "It was unclear if there was actual penetration or not." Resident 1's discharge instructions from the GACH dated 6/10/22 at 3:28 P.M., the discharge instructions indicated, "...Final diagnosis: Sexual Assault ..." The discharge instructions from GACH indicated Resident 1 had to continue antibiotics at home. On 6/9/22 at 2:24 P.M., an observation was conducted. Resident 1's room was located adjacent to Resident 2's room at the end of the hallway in Station 2. Resident 1 resided in a two-bedroom by herself with her bed located by the window. Resident 2 resided in the adjacent two-bedroom room by himself. On 6/9/22 at 3:26 P.M., an observation and an interview of Resident 2 was conducted. Resident 2 was sitting in a chair, holding a cane, and was watching a television show in his room. Resident 2 stated he used to go out of his room and did not know why he "now" had restrictions. Resident 2 stated he did not recall if he had gone to another resident's room. Resident 2 stated, "Maybe I have to start looking for a girlfriend. I want to hold hands with somebody, it was important to me because I always have a girl in my hand/arms. I used to have somebody with me always." On 6/9/22 at 4 P.M., a follow up observation of Resident 2 in his room was conducted. Resident 2 tried to go out of his room, but the CNA stopped him because he was on a one on one (constant observation of a staff member to a resident in a time) monitoring at the time of visit. On 6/9/22 at 3:46 P.M., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated Resident 1 was confused and was totally dependent to staff. CNA 1 stated Resident 1 was admitted to the hospital on 6/9/22 after the sexual assault. On 6/9/22 at 3:46 P.M., an interview with CNA 1 was conducted. CNA 1 stated Resident 2 had memory impairment and he forgot things like his name and his room. CNA 1 stated Resident 2 tended to go to another resident's room but was easily redirected. CNA 1 stated Resident 2 had wandering behaviors and were reported to the licensed nurses. CNA 1 further stated he witnessed Resident 2 entering other resident's rooms, and CNA 1 redirected Resident 2 out of the room. On 6/9/22 at 4:09 P.M., an interview with CNA 2 was conducted. CNA 2 stated she provided care to Resident 1 and Resident 2. CNA 2 stated Resident 1 was confused, required two persons assist, got nervous when staff moved her. CNA 2 stated Resident 2 was alert, oriented and could hold a conversation. CNA 2 stated Resident 2 would always ask for his room number. CNA 2 stated the staff had to look for him because he would push wheelchair-bound confused female residents from station 2 hallways to the lobby. CNA 2 stated Resident 2 would get mad when staff separated Resident 2 from the female residents, he became violent and swung his cane up the air. CNA 2 stated other CNAs were aware Resident 2 would go to other residents' rooms. CNA 2 stated his wandering behaviors were reported to the licensed nurses. CNA 2 stated Resident 2 was not on monitoring during the time of sexual assault on 6/9/22. On 7/11/22 at 3:16 P.M., a telephone interview with CNA 3 was conducted. CNA 3 stated she provided care to Resident 1 and Resident 2 during the night shift on 6/8/22. CNA 3 stated Resident 1 was nonverbal, yelled when she was being cleaned or changed. CNA 3 stated Resident 2 was independent, wandered around the station and was usually awake during the night shift. CNA 3 stated Resident 2 was aggressive towards staff and cursed everybody out. CNA 3 stated Resident 2 would sometimes walk naked in the hallway, and the licensed nurses would redirect him. CNA 3 stated on 6/9/22, after midnight, she heard Resident 1 yelling. CNA 3 stated she went into Resident 1's room and found Resident 1 lying on her left side, her pull ups (incontinence brief) was on the floor, her legs were around Resident 2's waist, while Resident 2, whose pull ups were to his knees, was on top of Resident 1 and was thrusting. CNA 3 stated, it was hard to see with their position that contact was made. CNA 3 stated she told Resident 2 to get out but Resident 2 refused. CNA 3 stated it took them 10 minutes until Resident 2 went out of Resident 1's room. CNA 3 stated Resident 2 was aggressive and said to CNA 3, "She gave me consents and I can do anything to her." CNA 3 stated there was stool on Resident 2's shirt and the police officer took the shirt. On 6/9/22 at 4:27 P.M., an interview and facility record review with LN 2 was conducted. LN 2 stated Resident 1 required staff assistance, she was nonverbal and would scream when staff changed her. LN 2 stated Resident 2 was alert, oriented, would walk up and down the hallway and asked for his room number. LN 2 stated she did not witness Resident 2 going into other residents' rooms nor received a report from the CNAs that Resident 2 went into other residents' rooms. LN 2 stated Resident 2 would stop in each residents' door and wandered around to find his room by walking up and down the hall. LN 2 stated there was no wandering assessment or care plan in Resident 2's record. LN 2 stated the staff did not consider Resident 2 as wanderer because he did not have an exit seeking behavior (wander or try to leave the facility without companion). LN 2 stated, "We could have prevented the incident if we had a sitter (one on one) and redirected him." On 7/11/22 at 1:16 P.M., a telephone interview with LN 3 was conducted. LN 3 stated Resident 1 was confused, required staff assistance with ADLs. LN 3 stated Resident 2 had an aggressive behavior at times, was rude and yelled at staff. LN 3 stated Resident 2 wandered around, walked down the hallway, would come to the nurse's station, asked for his room number, would go back to his room then will come out again. LN 3 stated Resident 2 would do the behavior three to four times during her shift. LN 3 stated she did not do any assessment or care plan related to Resident 2's wandering behavior. LN 3 stated she was not in the facility on 6/9/22 during the time of the sexual assault incident. LN 3 stated the incident could have been prevented if staff paid more attention to Resident 2's behavior. On 12/26/23 at 11:37 A.M., a telephone interview with the Assistant Director of Nursing (ADON) was conducted. The ADON acknowledged that Resident 1 and every resident should have been free from any form of abuse. A review of the facility's policy titled; "Resident Rights" revised December 2016 was conducted. The policy indicated, "...1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: ...c. be free from abuse..." A review of the facility's policy titled, "Wandering..." revised March 2019 was conducted. The policy indicated, "The facility will identify residents who are at risk for unsafe wandering and strive to prevent harm...1. If identified as at risk for wandering...or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety..." A review of the facility's policy titled, "Safety and Supervision of Residents" revised July 2017 was conducted. The policy indicated, "...Resident safety and supervision...to prevent accidents are facility-wide priorities...Systems Approach to Safety...2. Resident supervision is a core component of the systems approach to safety..." In violation of the above cited law/regulations, the facility failed to, including but not limited to: 1. Uphold Resident 1's right to treated with dignity and respect in an environment free from the serious mental and physical harms of sexual abuse. 2. Develop resident care plan to prevent resident sexual abuse by known wandering and cognitively impaired resident, Resident 2. More specifically, developing an accurate safety assessment of Resident 2's (an "aimless" movement from one place to another) behaviors, as well as development of interdisciplinary and core staff communication for the planning, monitoring, and evaluating of Resident 2's plan of care related to his wandering behaviors, to ensure Resident 2 did not interfere with oth