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 # CA00686020. 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), with a history of assaultive behavior, pushed Resident 1 to the ground. This failure resulted in Resident 1 sustaining swelling and discoloration to her left hand. 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 for assaultive behavior, initiated on 2/24/19, indicated Resident 2 pushed a resident on 2/24/19, kicked a Certified Nurse Assistant (CNA) on 1/31/20, kicked a CNA on 3/15/20, and slapped a resident on 4/10/20. The care plan indicated interventions, which included, "Monitor episodes of behavior and document...Administer medication as prescribed, monitor for side effects and effectiveness of medication and report to MD [medical doctor]...Encourage attendance of T.R. [therapeutic response] recommended groups/activities to increase positive behavior...Provide 1:1 counseling as needed...Resident [2] started on q [every] 15min [minute] checks for assaultive behavior...2 staff to go and care for resident at all times...Monitor [Resident 2] when he is in an activity area and assist with seating... ." Review of a facility document titled "STATEMENT OF ACCUSED," dated 4/23/20, at 2:40 p.m., indicated the person being accused was Resident 2 and his statement was "[Resident 1] tried to grab me when I was coming out the utility room so I pushed her down." A Behavior Note for Resident 2 dated 4/23/20, at 3:04 p.m., indicated, "Resident [2] was seen walking out of station 2 utility room, as he walked by [Resident 1] who was walking from her room towards the activity area, resident [2] pushed her causing her to fall to the floor...." A Nurses Note for Resident 2 dated 4/23/20, at 4:33 p.m., indicated, "[Resident 2] is being monitored Q15 minutes r/t [related to] assaultive BX [behavior], having pushed [Resident 1] down today...No new orders except for standing fall orders were noted...continuing to monitor." Review of Resident 1's Admission Record indicated Resident 1 admitted to the facility in 2004. A Nurses Note for Resident 1 dated 4/23/20, at 2:25 p.m., indicated, "Resident [1] was pushed by peer while she was walking down the hallway to her room, causing her to fall onto the floor...Resident c/o [complained of] pain 8/10 [pain severity scale where 0 is no pain and 10 is extreme pain] in her right ankle...." A Nurses Note for Resident 1 dated 4/24/20, at 4:19 a.m., indicated, "Monitoring resident for being pushed by peer. Swelling to left hand noted. C/o pain with due meds [medications] given." A Nurses Note for Resident 1 dated 4/24/20, at 7:19 a.m., indicated, "MD [medical doctor] in the unit and assessed residents (sic) right ankle...MD also assessed resident left hand and with discoloration and swelling noted. When MD checked ROM [range of motion], resident complained of pain. MD ordered Xray to left hand." Review of daily Nurses Notes from 4/24/20 to 5/31/20 for Resident 1 indicated nurses noted swelling and discoloration to Resident 1's left hand until 5/11/20. During an interview with the Unit Secretary (US) on 8/4/21, at 11:30 a.m., the US stated she witnessed Resident 2 push Resident 1 on 4/23/20. The US stated she was sitting at her workstation at Nursing Station 2 when she saw Resident 1 walk out of her room and head toward the activity room. The US stated Resident 1 was usually loud and vocal when she would exit her room but recalled Resident 1 was quiet at that time. The US stated Resident 2 was exiting the utility room, which was visible from the nursing station, and he appeared to be heading in the direction of his room. The US stated, out-of-nowhere Resident 2 pushed Resident 1, who lost her balance and fell to the ground. When asked if the US saw Resident 1 grab for Resident 2, the US stated she did not see that, and stated Resident 1 was not standing close to or walking near Resident 2 when the incident occurred. 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 another resident with a history of assaultive behavior. This violation had a direct or immediate relationship to the health, safety, or security of the patient.