Other·June 14, 2024

3The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident (ERI) #: CA00886803, Survey Event ID: 5DGN11. Representing the Department, HFES (Health Facilities Evaluator Supervisor) # 42432 State Citation (B) was written. 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. On 5/14/24 at 2:00 p.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding an incident involving Resident 1 and Resident 2. The Department determined the facility failed to protect the resident's right to be free from physical abuse by a resident when Resident 2 punched Resident 1 in the nose with a closed fist on 2/25/24, which caused Resident 1's nose to bleed. This failure caused Resident 1 to experience emotional distress and a physical injury. Findings: A review of Resident 1's face sheet (includes the patient's name, address, date of birth, insurance information, diagnoses, and emergency contact information) revealed a diagnosis of schizoaffective disorder, bipolar type (seeing and hearing things that are not reality, depression, and episodes of hyperactivity). A review of Resident 1's nurse's progress note, dated 2/25/24, indicated "[Resident 1] attempting to go to the bathroom, demanded roommate to get off the toilet so he could go. [Resident 2] upset and punched [Resident 1] in the face in bathroom both residents share. [Resident 1] had slight bleeding from nose, ice pack applied at nurses station and kept at nurses station until room change made for safety..." A review of Resident 2's face sheet revealed diagnoses of dementia with psychotic disturbance (mental state where someone is not sure what's real or not and has problems with memory). A review of Resident 2's progress note, dated 2/25/24, indicated "MD [doctor] in facility, assessed [Resident 2] d/t [due to] [Resident 2] punching peer on the nose with right hand. Per MD, noted swelling of right [3-5th fingers]..." A review of Resident 2's care plan, initiated on 3/13/23, indicated "...Inappropriate social behavior (yelling towards others)...resident can have outbursts towards others...when he doesn't get answers he wants..." A review of Resident 2's care plan, initiated on 3/13/23, indicated "...Assaultive behavior...resident assaulted a nurse at a previous placement..." A review of the same care plan indicated, "...11/14/23, spit in a staff members face...2/25/24 punched peer in the face..." During an interview with Resident 1 on 5/14/24 at 3:02 p.m., Resident 1 stated he and Resident 2 were in the bathroom and were "saying comments to each other" when Resident 2 punched him with a fist and bloodied his nose. Resident 1 stated staff intervened and separated them, then moved Resident 2 to a new room. Resident 1 stated the incident "stressed him out and messed with his program." During a concurrent interview and record review with Licensed Nurse (LN) 1 on 5/14/24 at 3:33 p.m., LN 1 confirmed Resident 2 punched Resident 1 in the nose. LN 1 stated Resident 2 had a history of assaultive behavior. A review of the facility's policy and procedure titled "Elder and dependent adult abuse/suspicion of a crime", revised 1/19/19, indicated "...[Name of facility] believes every person served...has the right to be free of...physical abuse...with resulting physical harm...or mental suffering...including...other residents..." Therefore, the Department determined the facility failed to protect the resident's right to be free from physical abuse by a resident when Resident 2 punched Resident 1 in the nose with a closed fist on 2/25/24, which caused Resident 1's nose to bleed. This failure caused Resident 1 to experience emotional distress and a physical injury. This violation had a direct or immediate relationship to the health, safety, and security of residents.