Other·February 23, 2022

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. The following reflects the findings of the California Department of Public Health during the investigation of facility reported incidents #CA00758226, #CA00759960, #CA00756784, #CA00758276, and #CA00756462. On 10/14/22, an unannounced visit was conducted at the facility to investigate facility reported allegations of resident to resident abuse and/or neglect. Facility failed to provide sufficient protection to prevent abuse and/or neglect for five of eight sampled residents, when: 1. Resident 5 was assaulted by Resident 2, who was accompanied by Resident 1, on 10/24/21, and then by Resident 1 on 11/4/21, and suffered from fear and increased anxiety, 2. Resident 3 was assaulted by Resident 1 on 10/11/21, and was injured on her chest and right wrist, 3. Resident 4 was assaulted by Resident 1 on 10/12/21, and experienced emotional distress with tearfulness, 4. Resident 6 was slapped by Resident 1 on 10/24/21, with the potential to cause emotional distress, and, 5. Resident 7 was not able to swallow and was given food by mouth by Resident 1 on 10/24/21, with the potential for choking and death. 1. A review of Resident 5's Admission Record indicated Resident 5 was admitted to the facility in early 2021. According to the Minimum Data Set (MDS, an assessment tool) dated 11/3/21, Resident 5 scored 14 out of 15 in a BIMS (brief interview for mental status) which indicated Resident 5 had intact cognition (normal memory). A review of Resident 5's clinical record titled, "SBAR-Alleged Abuse Report of Incident - 8hr- V3" dated 10/24/21, indicated, "... [Resident 5] was involved in an incident of alleged Physical Abuse ...at 16:10 [4:10 p.m.] ... [Resident 5] ...anxiously verbalizing the sequence of event, when an allege [sic] attacker [Resident 2] came in to [Resident 5's] room and tried to choked [sic] [Resident 5] using a plastic bag..." During an interview on 10/26/21, at 12:07 p.m., Resident 5 described the event on 10/24/21 "... [Resident 1] and [Resident 2] both came into my room. They wanted my roommate's wheelchair. I was telling them to leave, leave now please. They didn't respond to me... [Resident 2] grabbed the long white plastic bag and [Resident 2] stretched the bag out and came at me and tried to put it over my neck. I took it away from her, at the same time I was hollering..." Resident 5 further stated, " ...[staff name] the licensed nurse took the bags away and don't want me to be exposed to the possibility of a bag over my head while I'm sleeping ..." Resident 5 stated, "In my lifetime I have been abused a lot, I don't put up with it..." Resident 5 expressed, "..I thought I lost my mind when [Resident 2] came at me with the bag, she was so mad, she was shaking..." During an interview on 10/26/21, at 2:50 p.m., CNA 3 stated there was screaming from Resident 5's room on 10/24/21, and upon entry, Resident 1 and Resident 2 were both found in Resident 5's room. CNA 3 stated "[Resident 5] was in shock..." CNA 3 indicated Resident 5 wanted her door kept closed after the event. CNA 3 indicated there were three altercations involving Resident 1 with Resident 5, Resident 6, and Resident 7, during the evening of 10/24/21, and stated Resident 1's persistent behavior of going to other resident rooms and taking personal belongings contributed to the altercations with other residents. CNA 3 stated, "[Resident 1] have [sic] a cart full of stolen stuff of residents ..." CNA 3 further stated, " ...I wish we could do more to prevent this, I do not think other resident is safe here ..." A review of Resident 5's clinical record, "Social Services Note", dated 10/25/21, indicated, " ... [Resident 5] was asked how she was doing and became agitated as SS [Social Services] asked about the alleged abuse report. [Resident 5] ...stated that she does not feel safe ..." A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility in late 2020, with a diagnosis of dementia with behavioral disturbance (a general term for loss of memory, language, problem- solving and other thinking abilities that are severe enough to interfere with daily life along with behaviors such as verbal outbursts, hitting, wandering, and hoarding). A review of Resident 2's clinical record titled, "SBAR-Alleged Abuse Report of Incident- 8hr- V3" dated 10/24/21 indicated, "...[Resident 2] Known to have unpredictable behavior. Most often time wonders [sic] to other Residents room. Difficult to redirect triggering behavioral aggression...Place on Distant supervision for behavioral aggression...Pt [patient] continue [sic] to be unpredictable..." During a telephone interview on 10/25/21, at 11:55 a.m., the Assistant Director of Nursing (ADON) stated the facility was, "...Monitoring [Resident 2]'s behavior very closely via visual watch. When [Resident 2] is in the hall we redirect...Not on one-on-one [one staff assigned to be with the resident at all times]. We can start [one-on-one] though..." A review of Resident 2's care plan dated 10/25/21, indicated, " ...1:1 [one-on-one] staff monitoring until determined no longer necessary ..." A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility in late 2020, with a diagnosis of dementia (a general term for loss of memory, language, problem- solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 1's clinical record titled, "SBAR [SBAR-situation, background assessment, recommendation] Communication Form" dated 9/14/21, indicated, "...Resident seems to be getting more agitated than usual, resident wandering the hallway going in other residents rooms taking their personal belongings, when staff tried re-directing resident, resident got angry and yelling with clench fists in her language, grabbing staff and her roommate..." A review of Resident 1's care plan, in the "Focus" section showed "The resident has behavior ...hard to redirect and physical aggression (hitting others)" dated 10/24/21, indicated an intervention was initiated 10/25/21, "1:1 staff monitoring ..." A review of Resident 1's clinical record, "General Note", dated 10/25/21, at 3:39 p.m., indicated, "[Resident 1] is place on [1:1] for safety ..." A review of facility document titled, "[facility name] EVENT 5-DAY FOLLOW UP" dated 10/26/21, indicated, "...With [Resident 1's] behavior escalating, she will be kept on 1:1 until new medications can take effect." A review of Resident 1's clinical record titled, "Psychiatry Follow Up Note" dated 10/29/21, indicated, "...referred for ...increase physical aggression towards other residents...Plan ...Monitor risperidone [an antipsychotic medication used to treat mental conditions] ...Monitor for worsening target symptoms ..." A review of Resident 1's clinical records showed no evidence of monitoring the effectiveness of the risperidone. A review of Resident 1's clinical record titled, "Social Services" dated 11/3/21, indicated, "Psychiatrist adjusting medications due to increase in behaviors. Continue to monitor for changes in mood/ behavior and wandering. No further need for 1:1. DON aware." During an interview on 11/4/21, at 4:10 p.m., LN 5 confirmed he observed Resident 1's tendency to wander the facility and collect other residents' personal items from their rooms. LN 5 stated Resident 1's behavior was unpredictable and, "...I have a hard time keeping track of [Resident 1] when I have other residents to take care of." A review of Resident 5's clinical record titled, "SBAR-Alleged Abuse Report of Incident- 8hr- V3" dated 11/5/21 indicated, "...[Resident 5] was involved in an incident of alleged Physical Abuse ...at 23:30 [11:30 p.m.] ...loud and angry voices coming from the St. 2/3 hallway [an area of the facility where residents reside] ...on approach CNA was trying to redirect the aggressor [Resident 1] from [Resident 5's room] ...Aggressor difficult to redirect ...[Resident 1] went to [Resident 5's] room ...slapped [Resident 5] on the right hand] ..." During a concurrent observation and interview on 11/5/21, at 2:02 p.m., Resident 5 stated while she slept on 11/4/21 "...I realize someone was in the room with me. This didn't feel right, I sat up in bed. [Resident 1] was standing to left of my bed. I sat up and pulled my bedside table. I told [Resident 1] you need to leave. [Resident 1] was still touching my stuff, [Resident 1] really wanted my rose that my daughter gave me...She slapped me on my right hand ...I screamed ...I called 911 that minute as soon as they took her away ...It's not very safe here ...It took me a while to calm down ..." Resident 5 further stated she remembered the door was closed and blocked with a locked wheelchair before going to bed. When asked, Resident 5 stated, "I started to do this after prior incident [on 10/24/21] ... I didn't do this before." Resident 5 had a bluish- purple discoloration on the back of her right hand, approximately the size of a penny. Resident 5 further stated, " ...I do not trust what is going on, I am afraid to close my eyes at night, [Resident 1] in my room and aggressively in my room, I am afraid of that ..." During an interview on 11/5/21, at 3:04 p.m., CNA 5 indicated one-to-one monitoring of Resident 1 helped to protect the other residents in the facility. CNA 5 stated the one-to-one monitoring was stopped a few days prior, and she was not aware of additional interventions to prevent further incidents. CNA 5 indicated Resident 5 asked her why the one-to-one monitoring was stopped and stated Resident 5's expression was fearful. During a phone interview on 11/10/21, at 4:06 p.m., the private social worker (PSW) stated Resident 5 claimed Resident 1 and Resident 2 were threatening her verbally and physically. The PSW further stated Resident 5's mood was affected after the altercations with Resident 1 and Resident 2. The PSW explained Resident 5 had begun to block her room door at night with a wheelchair. The PSW further stated Resident 5 was scared and requested for placement at a different facility. During an interview on 11/12/21, at 2:17 p.m., CNA 5 confirmed Resident 5 placed her wheelchair against the door every night in order to know who came into the room. During a phone interview on 12/2/21, at 1:16 p.m., the Assistant Director of Nursing (ADON) stated, "I don't know why [Resident 1] was removed from one-to-one monitoring...it's usually social services, the DON [Director of Nursing] and the Administrator who will discuss if one-to-one monitoring is continued or removed." During a phone interview on 12/2/21, at 2:37 p.m., the SSD (Social Services Director) stated, "[Resident 1's] meds were being adjusted so it was determined one-to-one monitoring was no longer needed. It was a directive from the Interim DON [IDON]..." The SSD confirmed no interdisciplinary meeting was held to discuss the removal of one-to-one monitoring for Resident 1, and no specific recommendation was made by the physician. The SSD stated she did not review Resident 1's behavior prior to removal of Resident 1's one-to-one monitoring. The SSD stated, "I don't know who the IDON discussed with about removing [Resident 1's] one-to-one monitoring." The SSD further stated the expectation was to look if a resident showed any behaviors before making changes to a resident's interventions. During a phone interview on 12/2/21, at 2:56 p.m., the Administrator (ADM) stated, "[IDON] had a brief conversation he was going to try [Resident 1] without one-to-one monitoring." The ADM further stated, "I don't know, I'm not usually involved..." when asked who was involved in determining when to remove a resident from one-to-one monitoring. The ADM stated the interdisciplinary meeting could have met to discuss the removal of Resident 1's one-to-one monitoring. During a phone interview on 12/2/21, at 4:30 p.m., the DON stated she expected the following: a resident interview, staff interviews, a meeting of the interdisciplinary team which consisted of the DON, the Infection Preventionist (IP), the Director of Staff Development (DSD), the activities director, the SSD, and other members of staff to discuss whether a resident's one-to-one monitoring should be removed. The DON further stated she would involve the physician, and in cases of abuse, notify corporate before removing a resident's one-to-one monitoring. 2. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility in 2016. According to the Minimum Data Set (MDS, an assessment tool) dated 10/7/21, Resident 3 scored 14 out of 15 in a Brief Interview for Mental Status (BIMS) which indicated Resident 3 had intact cognition (normal memory). A review of Resident 3's clinical record titled, "General Note" dated 10/10/21, indicated "...Reported physical abuse; witnessed by [CNA 1] ...Stated she was attach [sic] by [Resident 1] after a dispute to prevent walker to be taken..." During a concurrent observation and interview on 10/14/21, at 10:55 a.m., Resident 3 indicated she was getting up to go for a walk on 10/10/21, and stated, " [Resident 1] wanted my walker ...I told her no, and she got angry and grabbed me ..." Resident 3 pointed to her mid-upper chest where the skin had reddish purple discoloration approximately the size of a silver dollar coin, and to an area approximately two inches long on her right outer wrist which appeared bruised. Resident 3 indicated she was injured trying to stop Resident 1 from taking her walker. During an interview on 10/14/21, at 11:54 a.m., CNA 15 stated, " ...[Resident 1] likes to collect wheelchairs and put them in her room. At first, she says no, but the next day she lets the staff take out the wheelchairs ..." During an interview on 10/14/21, at 3:24 p.m., Licensed Nurse (LN) 1 stated, "[Resident 1] is aggressive... needs serious monitoring...[Resident 1] might do it again with another resident..." During an interview on 10/15/21, at 12:47 p.m., LN 4 stated Resident 1 wandered into other residents' rooms and collected their personal items. LN 4 stated Resident 1's behavior increased the chance of another altercation. A review of Resident 3's clinical record titled, "Treatment Administration Record" dated, October 2021, indicated an order to begin treatment on 10/11/21, "...Hematoma [a pool of mostly clotted blood that forms in an organ, tissue, or body space caused by a broken blood vessel that was damaged by injury or surgery] over senile purpura [bruising that affects older adults] on midsternal chest [breastbone]. Apply bacitracin [antibiotic ointment to treat/prevent infection]...monitor for skin breakdown...every shift ..." A review of Resident 1's care plan initiated on 10/12/21 indicated, "...[Resident 1] is physically aggressive towards other...episode of aggression towards other ...going into residents' rooms and unable to be redirected ..." Further review of Resident 1's care plan "Interventions/Tasks" indicated, "...Monitor for behavior of physical aggression towards other redirect if behavior seen... Psychiatric/Psychogeriatric consult as indicated...[Resident 1] was transfer to Rm [room number] ..." During an interview on 11/5/21, at 3:51 p.m., LN 2 stated Resident 1's room was changed often to separate her from residents with whom she had altercations. LN 2 stated the room changes made Resident 1 more confused and did not help her. 3. A review of Resident 4's Admission Record indicated Resident 4 was admitted to the facility in January of 2021. According to the MDS dated 8/6/21, Resident 4 scored 15 out of 15 in a BIMS which indicated Resident 4 had normal memory. A review of Resident 4's clinical record titled, "SBAR ...Alleged Abuse Report of Incident- 8hr -V 3" dated 10/12/21, indicated, "...[Resident 4] heard alarm from emergency door by the kitchen