Health inspection·June 27, 2024

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident 893504: Title 42 Code of Federal Regulations part §483.12(a)(1) - Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. On 4/9/24, an unannounced visit was conducted at the facility to investigate a Facility Reported Incident regarding an allegation of abuse towards two long-term care patients (Patient 1 and Patient 2). The facility admitted Patient 1, a 75-year-old-male, on 10/18/23, with diagnoses that included Atrophy (muscle wasting), Dementia (symptoms that affect memory, thinking and social ability), and Anxiety (feeling of worry and nervousness). Patient 1 had the ability to verbalize and make needs known. The facility admitted Patient 2, an 80-year-old-female, on 10/11/2021, with diagnoses that included Unspecified Atrial Fibrillation (abnormal heart beating), Generalized Muscle Weakness, and Alzheimer's Disease (a type of dementia that affects memory, thinking, and behavior). Patient 2 had a Brief Interview for Mental Status (BIMS, cognitive assessment, score 13 and above cognitively intact; 12-8 cognitively impaired, 7-0 severely impaired) score of 13 out of 15. Based on observation, interview, and record review, the facility failed to ensure two of two sampled patients (Patient 1 and Patient 2) were free from verbal abuse when Activity Assistant (AA) yelled, cursed and threw popcorn. This failure resulted in: a. Patient 1 not enjoying activities. b. Patient 2 experiencing terror and fear. This failure had the potential to expose all patients to verbal abuse. The facility failed to adhere to adhere to Title 42 Code of Federal Regulations part §483.12(a)(1). Findings: a. During a concurrent observation and interview on 4/9/24 at 4:03 p.m. with Patient 1, in the dining room, Patient 1's brow was folded and moved his head right to left shaking motion. Patient 1 stated, "I was in shock. He [AA] yelled and cursed" at him and Patient 2 during activities on 4/7/24. Patient 1 stated, AA lead activities at the facility and activities were supposed to be "fun and it wasn't that day [4/7/24]." During a review of Patient 1's "History and Physical (H&P)," dated 10/24/23, the "H&P" indicated, Patient 1 had the mental capacity to make medical decisions. During a review of Patient 1's "Weekly Summary Note (WSN)," dated 4/25/24, the "WSN" indicated, "Resident [Patient 1] is alert and oriented, able to verbalize needs." b. During a concurrent observation and interview on 4/9/24 at 4:05 p.m. with Patient 2, in the dining room, Patient 2's eyes watered. Patient 2 stated during activities on 4/7/24, AA "picked up my popcorn and threw it at me." Patient 2 stated, AA yelled at her. Patient 2 stated, "I was terrified, I am afraid he [AA] will come back." During a review of Patient 2's "MDS," dated 1/21/24, the "MDS" indicated, "Section C- Cognitive Patterns. . . C0500. BIMS Summary Score 13." During a review of Patient 2's "PN," dated 4/7/24, the "PN" indicated both Patient 2 and Patient 1 were both yelled at during activities by AA, Patient 2 was "scared," and her popcorn was thrown on the floor. During an interview on 4/9/24 at 4:10 p.m. with Administrator, Administrator stated on 4/7/24, Receptionist informed him AA yelled at Patient 1 and Patient 2 during activities. Administrator stated he was the facility abuse coordinator, and the expectation was staff "Cannot yell and mistreat them [patients]." Administrator stated AA was verbally abusive during activities to Patient 1 and Patient 2. Administrator stated the verbal abuse should not have happened. During an interview on 4/9/24 at 6:18 p.m. with AA, AA stated on 4/7/24 at approximately 11 a.m., during activities "I yelled at them [Patient 1 and Patient 2] and lost my cool." AA stated he raised his arms up at Patient 2 and "I told her [Patient 2] if you don't want to be here then leave." AA stated, "Yeah I might of said a few curse words" to Patient 1 and Patient 2. AA stated, "I know that I should not have done what I did, it was verbal abuse." AA stated he should not "yell at the residents [patient's]." During a concurrent interview and record review on 4/9/24 at 7 p.m. with Receptionist, the Receptionist Written Incident Statement (WIS) dated 4/7/24 was reviewed. The WIS indicated, "[AA] threw [Patient 2's] popcorn from the table to the floor." Receptionist stated AA yelled at Patient 1 and Patient 2 "Get the [curse word] out of the dining room you guys are getting me upset." Receptionist stated, "He [AA] was screaming at them [Patient 1 and Patient 2] very bad." Receptionist stated the facility staff are expected to "treat them [patients' ] with respect and the same way you want to be treated." During a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention," dated 12/31/15, the P&P indicated, "Each resident has the right to be free from verbal, sexual, physical, and mental abuse. . . Residents [Patients] must not be subjected to abuse by anyone, including, but not limited to, facility staff. . . Purpose To ensure the resident's rights are protected. . . SECTION 2: DEFINITIONS. . . VERBAL ABUSE: Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability." The facility failed to protect the rights of Patient 1 and Patient 2 from verbal abuse. This failure resulted in Patient 1 not enjoying activities, Patient 2 experiencing terror and fear. This failure had the potential expose all patients to verbal abuse. This violation had a direct or immediate relationship to the health, safety, or security of patients and constitutes a class "B" citation.