Other·November 5, 2021

§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. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion[.] The following reflects the findings of the California Department of Public Health during the investigation of a Facility Reported Incident #: 740342. On 6/16/21, at 1:35 PM, an unannounced visit was conducted at the facility to investigate a report of one resident assaulting another resident. Resident 1 was a 90-year-old man admitted to the facility on 5/6/21 with diagnoses that included dementia (a chronic mental disease that affects memory, mood, and judgement) and heart failure. The facility reported that Resident 1 was assaulted by Resident 9 by hitting him in the face with a can of soup, resulting in a facial fracture and cuts to his face and hand, and increased pain for several days afterwards. Resident 9 was a 37-year-old man admitted to the facility on 9/14/19 with diagnoses that included schizoaffective disorder, a serious mental illness that can result in altered perceptions of reality. The facility failed to ensure Resident 1 was not physically abused by Resident 9. During a review of a letter sent to the Department, dated 6/17/21, the letter indicated there was a "Resident to resident altercation," on 6/15/21, at approximately 9 AM. The letter indicated that on 6/15/21, at approximately 9 AM, Resident 1 entered Resident 9's room by mistake. Resident 9 yelled at Resident 1 to get out, and when he did not, Resident 9 hit Resident 1 in the face with a soup can. The letter indicated staff provided first aid to Resident 1, then transferred him to an Emergency Department. The letter indicated Resident 1 "did sustain cuts and abrasions [scrapes] to his face and hand, some which required sutures [stitches]. Additionally, he sustained a nasal [nose area] bone fracture. Police interviewed [Resident 9] and asked him about right versus wrong. He admitted to assaulting [Resident 1]. Police ran a search and [Resident 9] had other warrants for his arrest. Police arrested [Resident 9] for the assault and the outstanding warrants. [Resident 9] is discharged to police custody and will not be returning." During an observation on 6/16/21, at 2 PM, Resident 1 was noted with swelling and lacerations to his face. During an interview on 6/16/21, at 1:35 PM, with DON (Director of Nursing), DON stated the incident happened the previous day. The DON stated Resident 1 was found in Resident 9's room with lacerations to Resident 1's face. Resident 1 was sent to the hospital and diagnosed with a broken nose and multiple face lacerations and a wrist laceration. DON stated Resident 9 had told her that he had hit Resident 1 at least three times with an unopened can of soup because Resident 1 was in his room. The DON stated Resident 9 was arrested later that day by local police. During a review of Resident 1's "Admission Record," it indicated he was 90 years old with diagnoses that included "dementia with Lewy bodies," which cause a progressive decline in mental abilities, especially problems with memory. During a review of Resident 9's "Admission Record," it indicated he was 37 years old with diagnoses that included "Schizoaffective disorder," a serious mental disorder in which people interpret reality abnormally and may result in extremely disordered thinking and behavior that impairs daily functioning. During a review of Resident 1's Progress Notes, dated 6/15/21, at 12:03 PM, the Progress Notes indicated, ". . .[Resident 1] was hit in the face with a can at least 3 times by [Resident 9] causing injuries to nose, face and right hand. [Resident 1] had gone into [Resident 9's] room by mistake and [Resident 9] had yelled at him to get out or he will hit him. [Resident 1]. . . was then hit in the face, he attempted to put up his hands to protect himself and sustained a cut to the hand." The Progress Note was written by the DON. During a review of Resident 1's "Computed Tomography" (a type of x-ray), dated 6/15/21, at 1:09 PM, it indicated, "right nasal bone fracture with regional soft tissue swelling." During a review of Resident 1's Progress Notes, dated 6/15/21, at 1:57 PM, the Progress Notes indicated, "Resident [9] hit the male peer [Resident 1] with a food can on his face. Victim had swelling and bleeding on the right eye and bridge of nose. On asking resident (suspect) [Resident 9] reported that he hit the victim [Resident 1] with a food can because victim was into his room and touching his stuff. On asking if suspect have any injury on his hands suspect stated "I have not punched him with my hands, I hit him with the food can. He was not going out of my room and was touching my stuff." The Progress Note was written by Licensed Vocational Nurse (LVN) 1. During a review of Resident 1's Progress Notes, dated 6/16/21, at 6:34 AM, the Progress Notes indicated, "[Resident 1] sustained injuries to the nose, face and hands. Pain meds given to relieve his pain and discomfort." The Progress Note was written by LVN 2. During a review of Resident 1's Medication Administration Record," (MAR) for the month of June 2021, it indicated he was given no medication for pain in the seven days prior to the incident. The MAR indicated Resident 1 received narcotic pain medication for six consecutive days after the incident. During a review of Resident 1's Care Plan, dated 6/15/21, the Care Plan indicated Resident 1 had a laceration to his wrist measuring 1 centimeter (cm) x 1 cm; a nose laceration measuring 1 cm; a right eye laceration measuring 1 cm x 1 cm; and a superficial scratch to his lower right eye/upper cheek. During an interview with LVN 1, on 8/30/21, at 3:55 PM, LVN 1 stated she recalled the incident on 6/15/21, when she saw Resident 1 sitting outside Resident 9's room, in his wheelchair, crying, with blood on his face. LVN 1 stated Resident 1 was saying 'can of food, can of food.' LVN 1 stated she looked in Resident 9's room and saw blood on the floor and asked Resident 9 what had happened. LVN 1 stated Resident 9 had stated to her 'he was touching my stuff so I hit him with a can of food.' LVN 1 stated she noted a can of food on the floor with a dent in it. LVN 1 stated first aid was given to Resident 1 and emergency services were called. The facility's policy and procedure, titled "Abuse Prohibition and Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime in the Facility Policy and Procedure," dated 3/18, indicated, "This facility prohibits and prevents abuse. . .of residents. . . Each resident has the right to be free of. . . physical [abuse]. . . Residents must not be subjected to abuse by anyone, including but not limited to. . .other residents. . . .Orientation program upon hire will include review of facility's policy on Prohibiting and preventing all types of abuse. . . identifying what constitutes abuse. . . Understanding behavioral symptoms of residents that may increase the risk of abuse and. . . how to respond. These symptoms, include, but are not limited to. . . wandering. . . behaviors. . . . All employees and volunteers will be oriented to their role in abuse prevention as mandated reporters and that abuse will not be tolerated in this facility. The facility has the structure and process to provide the needed care and services to all residents, which includes, but is not limited to the provision of a facility assessment to determine what resources are necessary to care for its residents competently. . . The Facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse. Ongoing Resident Assessments and Care Planning for appropriate interventions are performed to monitor resident needs and address behaviors that may lead to conflict. . . such as. . .rummaging through other's property; wandering into other's rooms/space. . ." The Care Plan for Resident 1, dated 6/7/21, indicated he had been identified as having ". . .needs and behaviors which may lead to increase risk for conflict with other peers/staff and possible neglect [related to] Resident [with] behaviors of entering other resident's room." The goal for Resident 1 was "Resident will be safe from possible neglect or conflict due to identified behaviors or increase care needs." In violation of the above cited standards, the facility failed to protect Resident 1 from physical abuse from Resident 9. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.