Health inspection·August 31, 2021

F600 Free from Abuse and Neglect Section 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. Section 483.12(a) The facility must- Section 483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 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. The following reflects the findings of the California Department of Public Health during an investigation of facility reported incident # CA00688063. The inspection was limited to the specific facility reported incident and does not represent the findings of a full inspection of the facility. The Department determined that the facility failed to ensure a resident (Resident 1) was free from physical abuse when another resident (Resident 2), who had been displaying an increase in behaviors, grabbed Resident 1, and held her head in a headlock (a hold in which the aggressor encircles a victim's head with one arm). This failure resulted in Resident 1 sustaining redness to her neck area and increased the risk of Resident 1 experiencing a decline in her emotional wellbeing. Findings: Review of Resident 2's Admission Record indicated Resident 2 admitted to the facility in 2005 with diagnoses, which included schizoaffective disorder (a mental health disorder characterized by abnormal thought processes and an unstable mood). Review of Resident 2's care plan titled, "Lability of Mood and BX [behavior]," created on 5/2/2014, indicated, "Resident's mood and BX fluctuates from pleasant to hostile. Mood and BX increases/changes every 7-8 weeks. May be verbally abusive and assaultive when cycling [a pattern of frequent, distinct episodes]." The care plan had interventions, which included, "Administer medications as prescribed by Psychiatrist, monitor for side effects, and report any changes...Encourage attendance of TR [therapeutic responses] recommended groups/activities to increase positive behavior...Observe and monitor for mood fluctuation and document...Offer 1:1 Counseling as needed...." Review of Resident 2's behavior monitoring log for labile [easily altered] moods for April and May 2020 indicated Resident 2 had no episodes of labile moods from 4/1/20 to 4/29/20 and had 32 episodes of labile moods from 4/30/20 to 5/10/20. Review of a Behavior Note for Resident 2 dated 5/10/20, at 8:30 a.m., indicated, "Resident [2] placed on alert charting for resident to resident altercation. Resident [2] grabbed and placed [Resident 1] in headlock." Review of an Interdisciplinary Team Progress Note for Resident 2 dated 5/13/20, at 11:22 a.m., indicated, "Resident's quarterly care plan conference done today...Case manager was made aware of assaultive behavior and she asked if this is psychiatrically driven or medical. I told her that based on how residents [sic] behavior is, resident at times tends to be like this when he is in the state of what we call "cycling"...." Review of Resident 1's Admission Record indicated Resident 1 admitted to the facility in 2018. Review of a Change of Condition Note for Resident 1 dated 5/10/20, at 8 a.m., indicated, "Resident to resident altercation. [Resident 2] grabbing resident [1] and placed her in a headlock." Review of a Nurses Note for Resident 1 on 5/10/20, at 1:23 p.m., indicated, "Resident...grabbed and assaulted by peer from station 2. Resident sustained some redness to upper chest area...." Review of a Nurses Note for Resident 1 on 5/11/20, at 7:03 a.m., indicated, "Resident was assessed in her room with [name], Supervisor as it r/t [relates to] altercation by peer on 5/10/20. Full assessment noted slight redness of skin at the left clavicle [collarbone]...." Review of a Nurses Note for Resident 1 on 5/11/20, at 2:04 p.m., indicated, "On monitoring for s/p [status post] assaulted by station 2 male peer. Slight redness noted on left clavicle area.... " During an interview with the Activities Director (AD) on 8/3/21, at 2 p.m., the AD stated he witnessed the altercation between Resident 1 and Resident 2 on 5/10/20. The AD stated Resident 2 was sitting in his wheelchair in an alcove and Resident 1 was walking by. The AD stated he heard a scream and when he turned around, he saw Resident 2 holding Resident 1's head in a headlock. During an interview with Licensed Nurse (LN) 1 on 8/3/21, at 2:05 p.m., LN 1 stated she witnessed the altercation between Resident 1 and Resident 2 on 5/10/20. LN 1 stated she heard Resident 1 yelling, and when she went to investigate, she saw Resident 2 holding Resident 1 in a headlock. LN 1 stated she observed redness around Resident 1's neck afterwards. During an interview with Resident 1 on 8/6/21, at 11 a.m., Resident 1 stated she remembered the incident when Resident 2 grabbed her neck and held her in a head lock. Resident 1 stated she was just walking by Resident 2, who was sitting in his wheelchair, when he grabbed her. Resident 1 stated her neck hurt afterwards. During an interview with LN 2 on 8/12/21, at 12:45 p.m., LN 2 stated, when Resident 2 started to "cycle," his behaviors would increase for a few days. LN 2 stated Resident 1's behaviors were mostly him becoming loud and talkative, he would yell out peoples' names down the hallway, and would make hallucinatory statements. LN 2 stated staff would notify the physician when Resident 2 would show an increase in his behaviors. During a concurrent interview and record review with the Social Services Assistant (SSA) on 8/12/21, at 2:50 p.m., the SSA stated he assisted with the development and revisions of behavioral care plans. The SSA reviewed Resident 2's care plan for lability of mood and behavior and confirmed Resident 2 experienced a cycle every seven to eight weeks. The SSA stated, at times the period between Resident 2's cycles was shorter or longer. The SSA stated, when Resident 2 went through a cycle he would become labile, and described it as the resident would become loud, he would scream in the hallway, and he would grab for staff or peers. The SSA stated the psychiatrist did monthly psychiatric evaluations on all residents and would review the monthly behavior monitoring logs. The SSA stated staff should have been notifying the physician whenever a resident had a change in their mood or behaviors before the monthly psychiatric evaluation. The SSA stated the standard protocol was for staff to notify him whenever a resident had a change from their baseline mood or behavior so that he may follow-up with the resident. The SSA reviewed Resident 2's behavior monitoring log for labile moods and confirmed the increase in episodes starting 4/30/20. The SSA reviewed social services notes during 4/30/20 to 5/10/20 and stated he did not find documented evidence he was aware of the increase in Resident 2's lability until after the altercation on 5/10/20. In an email received on 8/16/21, at 2:16 p.m., from the Director of Medical Records (DMR), the DMR responded to the Department's request for documented evidence the staff notified the physician of Resident 2's increase in mood and behavior prior to the altercation on 5/10/20. The DMR stated, "In review of [the physician's] progress notes I did not see any notifications to the Doctor before 5/10/20." Review of a facility policy and procedure titled "Elder and Dependent Adult Abuse/Suspicion of a Crime," revision date 1/9/19, indicated, "Persons served must not be subjected to abuse by anyone, including, but not limited to...other residents...." Therefore, the Department determined the facility failed to: Ensure a resident was free from physical abuse from a resident, who had been displaying an increase in behaviors. This violation had a direct or immediate relationship to the health, safety, or security of the patient.