Other·March 21, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported Incident #CA00882107, Survey Event ID: DJV511 Representing the Department, HFEN #43071 State Citation (B) was written. 483.12-Freedom from Abuse, Neglect, and Exploitation (a)(1) Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone. On 2/12/24 at 12:50 p.m., an unannounced visit was conducted at the facility for the investigation of a facility reported incident. The department determined the facility failed to protect one of three sampled residents (Resident 1) from verbal abuse when Certified Nursing Assistant (CNA) 1 told Resident 1, " I could kill you" on 1/26/24. This failure resulted in verbal abuse and potential psychological harm for Resident 1. Findings: Review of a facility reported incident received on 1/28/24, indicated, "...Alleged Perpetrator [someone who has committed a crime]...[CNA 1]...Date of Alleged Event: 01/26/2024...Resident [Resident 1] reported to nurse that on Friday, CNA made statement, " I could kill you and nobody would know." Review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility in early 2024 with multiple diagnoses including anxiety disorder, heart failure, difficulty in walking, and muscle weakness. Review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 1/18/24, indicated Resident 1 had intact cognition with a score of 14 (The assessment uses a points system that ranges from 0 to 15 points, 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). During an interview on 2/12/24, at 2:52 p.m., CNA 2 stated either on January 26th or 27th, CNA 1 called her to Resident 1's room to assist with his care. CNA 2 stated CNA 1 and Resident 1 were talking when CNA 1 told Resident 1, " I will kill you." During an interview on 2/12/24, at 3:26 p.m., Licensed Nurse (LN) 1 stated Resident 1 informed her on Sunday, 1/28/24, around 4:15 p.m., that CNA 1 told him on Friday 1/26/24, that, "I can kill you and get away with it." LN 1 stated Resident 1 told her that when CNA 1 made the comment, CNA 2 was in his room's doorway, exiting the room. LN 1 stated CNA 1 was working on 1/28/24 so she confronted CNA 1. LN 1 further stated CNA 1 confirmed she did say that and was just joking. LN 1 stated Resident 1 told her that CNA 1 did not have a joking face when she made the comment. LN 1 added Resident 1 told her that CNA 1 went back to him an hour later and apologized and said she was kidding. LN 1 stated Resident 1 was very upset. LN 1 stated the words CNA 1 chose to use were very threatening. LN 1 stated when she informed Resident 1 that they (the facility) took CNA 1 off the schedule, Resident 1 was very appreciative and was relieved. During a phone interview on 2/12/24, at 4:56 p.m., Resident 1 stated CNA 1 came up to his bed and was mad because he was pressing his call light too much. Resident 1 stated CNA 1 told him, "Do you know I can kill you in your sleep and no-one would know nothing." Resident 1 stated he told her to get out of his room. Resident 1 stated later CNA 1 came back to apologize. Resident 1 added, "I told her to get out of my room. I was scared for my life. I was getting nightmares because of this lady. I got nightmares that she came to my bed and had bullet on my forehead." Resident 1 further stated, "I was scared she was going to come back and hurt me, that's why I left the facility. I couldn't even walk." Resident 1 stated he was very upset about the comment made to him by CNA 1. During a phone interview on 2/13/24, at 3:11 p.m., CNA 1 stated on Friday 1/26/24, in Resident 1's room, herself and CNA 2 were providing care to Resident 1 when she told Resident 1, "I could kill you." CNA 1 stated it just came out of her mouth and she didn't mean to say it. CNA 1 stated she apologized to him when she went back to answer his call light again. CNA 1 stated Resident 1 told her it was ok, and he already forgot about it. CNA 1 stated on Sunday morning, she heard from another CNA that Resident 1 was upset about it. CNA 1 stated the Director of Nursing (DON) called her on Sunday and told her the comment she made was verbal abuse towards Resident 1, and she was taken off the schedule. During a concurrent interview with the Administrator (ADM) and the DON on 2/12/24, at 5:58 p.m., the DON stated LN 1 informed her on 1/28/24, that Resident 1 voiced that CNA 1 made a statement that she would kill him, and no one will know about it. The ADM stated on Sunday 1/28/24, around 4 p.m., he received a call from the DON that Resident 1 claimed CNA 1 told him, "I can kill you and no one would know about it." The ADM stated he came to the facility the same day and spoke with Resident 1. The ADM stated Resident 1 told him that on Friday 1/26/24, CNA 1 was providing care to him when she made the comment. The ADM stated Resident 1 told him that CNA 1 came in later and apologized to him. The ADM stated CNA 2 witnessed the incident. The ADM stated CNA 1 made an inappropriate comment to Resident 1 and that was not acceptable. Review of Resident 1's "Change in Condition Evaluation" record dated 1/28/24, indicated, "...PATIENT [Resident 1] ACCUSED A CNA VERBALIZED INAPPROPRIATE VERBIAGE [words] TO THE PATIENT. PT [patient] REPORTED TO NURSE. NURSE REPORTED TO ADMINISTRATOR AND DON. CNA TOOK OFF ASSIGNMENT, IMMEDIATELY...PT AWARE OF ALL ACTIONS BEING TAKEN AND APPRECIATES THE EFFORTS..." Review of Resident 1's record titled "Follow-up Documentation" dated 1/29/24, indicated, "...Resident is on monitoring for accusation of inappropriate verbiage day #1. Nurse spoke to resident, resident reported having a stressful past few days and reported chest pain...Resident reported feeling anxious and stressed...." Review of Resident 1's Social Services note dated 1/29/24, indicated, "Followed up with resident regarding incident...Resident verbalized still feeling stressed over incident...He was appreciative for writer following up and talking with him. He would like to coordinate discharge for tomorrow if possible...Writer encouraged him to express his feelings and concerns to staff when needed..." Review of Resident 1's Social Services note dated 1/30/24, indicated, " Resident discharged home...on 1/30/24...Health/wound teachings and medication reviewed with resident by LN. Wheelchair was ordered and delivered to facility... prior to discharge...Discharge was resident driven, risk vs [versus] benefits explained to resident...Resident sent with 5 days of wound care supplies..." Review of the facility policy titled "Abuse Prohibition Policy and Procedure" dated 2/23/21,"...HealthCare Centers prohibit abuse...Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a patient, such as telling a patient that he/she will never be able to see his/her family again...The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, and involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property..." Therefore, the department determined the facility failed to protect one of three sampled residents (Resident 1) from verbal abuse when CNA 1 told Resident 1, " I could kill you." This failure resulted in verbal abuse and potential psychological harm for Resident 1. This violation had a direct or immediate relationship to the health, safety, and security of residents.