Other·September 6, 2023

The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident 844621. The inspection was limited to the specific Facility Reported Incident investigated during an Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the Department: 38993, HFEN A deficiency was written for Facility Reported Incident #844621 at F-tag/S/S F689/G 42 Code of Federal Regulations, part 483.25 Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Based on interview and record review, the facility failed to provide supervision for one of three sampled residents (Resident 1) when Resident 1 was not in staff's line of sight (where staff can observe at all times) while up in her wheelchair. This failure resulted in Resident 1 and Resident 2 having a resident-to-resident altercation and Resident 2 falling to the floor, sustaining a right hip fracture (broken bone) requiring hospitalization and the need for surgical intervention. Findings: During a review of the "Report of Suspected Dependent Adult/Elder Abuse (SOC 341-form used to report suspected abuse)" dated 6/8/23, completed by the facility, the SOC 341 indicated, "Writer call to Resident [Resident 1] room by nursing staff, per CNA [certified nursing assistant], 'Walked in room [X], near doorway. [Resident 2] was sitting on floor. [Resident 1] was sitting in her wheelchair and had [Resident 2] by the hair and kicked [Resident 2] in the leg [right] as CNA separated them [Resident 1] stated, 'You better stop taking my things.'" During a review of Resident 1's (aggressor) "Progress Note" (PN), dated, 5/9/23 (one month prior to current incident [6/8/23]), at 9:32 a.m., the PN indicated, "IDT [Interdisciplinary Team-group of professionals who work together to discuss about resident care needs] . . .On 5/8/23 at approx. [approximately] 1:30 pm, staff member reported she witnessed [Resident 1] in dinning [sic] room in her w/c [wheelchair]. There was a female [Resident 4] standing beside [Resident 1], when [Resident 1] stood up from her w/c and reached over to the female resident and with a closed fistmade [sic] contact to the female residents left arm. . .[Resident 1] is very territorial (guard or defend belongings) with her space and does not like confused (mentally impaired) residents approaching her space. . .IDT REC [recommendation]. . .keep in line of sight when up in w/c." During a review of Resident 1's "Care plan" (CP-specific care needs of resident), dated 5/8/23 (one month prior to current incident [6/8/23]), the CP indicated, "[Resident 1] had a resident-to-resident incident where she made contact with another female [Resident 4] left arm. . .Interventions. . .continue to be in the line of sight of staff when up in wheelchair. . ." During a review of Resident 1's"Care plan" revised on 5/8/23 (one month prior to current incident [6/8/23]), the CP indicated, "Behaviors: Flippin others off [showing anger or frustration toward a person] at random. . .Cursing at others. . .H/O [history of] striking out at others. . .Unprovoked physical aggression [hostile]/striking out. . .likes her space and doesnt [sic] like others approaching her. . .interventions. . .Keep in line of sight when up in w/c." During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool), dated 4/21/23, the MDS indicated, "BIMS [Brief Interview for Mental Status) Summary Score. . .4 (0-7 suggests severe impairment)." During a review of Resident 1's "Order Summary Report" (OSR), dated 6/1/23, the OSR indicated, Resident 1 diagnoses included "schizophrenia (a mental condition involving breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation). . .unspecified dementia (progressive or persistent loss of intellectual functioning especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), and anxiety (mental condition characterized by excessive apprehensiveness about real or perceived threats)" and Resident 1 was being treated with "bupropion (medication used to treat depression)". . ."buspirone (medication used to treat anxiety)" for behaviors of "unprovoked physical aggression." During a review of Resident 2's (victim) "Progress Notes" (PN), dated 6/8/23, at 7:30 a.m., the PN indicated, "Writer call [sic] to resident room by nursing staff, per CNA, 'walked in room [X], near doorway. [Resident 1] was sitting in her wheelchair and had [Resident 2] by the hair and kicked [Resident 2] in the leg [right] as CNA separated them. 'Per CNA, '[Resident 1] stated, 'you better stop taking my things.'" During a review of Resident 2's PN, dated 6/8/23, at 3 p.m., the PN indicated, "Resident complain of pain to right hip area. . .received order for: X-ray to right hip. . ." During a review of Resident 2's PN, dated, 6/8/23, at 4:56 p.m., "Received order from [Physician] to send resident to ER [Emergency Room] for evaluation due to increase c/o [complaint of] pain." During a review of Resident 2's "Orthopedic (branch of medicine dealing with the correction of deformities of bones or muscles) Consultation" (OC), from the acute hospital, dated 6/9/23, the OC indicated, ". . .female who came to the hospital because of after a GLF [ground level fall] at [Facility Name]. . .the patient had an altercation with another resident at [Facility Name] causing her to fall. Impression: Fracture of the right femoral neck (fracture of the right femur [thigh bone] within the hip joint). . ." During a review of Resident 2's PN, from the acute hospital, dated 6/10/23, at 1:19 p.m., the PN indicated, "Assessment/Plans. . .Fracture of femoral neck, right, closed. . .underwent right hip hemiarthroplasty [replacing half of the hip joint]. . ." During a review of Resident 2's "Order Summary Report" (OSR), dated 6/1/23, the OSR indicated, Resident 2 diagnoses included "psychotic disturbance (progressive or persistent loss of intellectual functioning especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), and anxiety." During a review of Resident 2's MDS dated 5/18/23, the MDS indicated, "BIMS Summary Score. . .00 (0-7 suggests severe impairment)." During an interview, on 6/12/23, at 11:14 a.m., with CNA 1, CNA 1 stated, on the day of the incident (6/8/23), it was Resident 1's first day of being off one-to-one (having a staff member always assigned only to the resident) supervision. CNA 1 stated, she and CNA 2 got Resident 1 up in her wheelchair prior to breakfast. CNA 1 stated, she and CNA 2 were passing breakfast trays and heard Resident 1 speaking loudly. CNA 1 stated, when she arrived in Resident 1's room, she noted Resident 1 sitting in her wheelchair and Resident 2 was sitting on the floor. CNA 1 stated, CNA 2 was in-between Resident 1 and Resident 2, and Resident 1 was "swinging" at Resident 2. CNA 1 stated, Resident 1 was saying "curse words" and Resident 2 was saying Resident 1 kicked her on the right side of the leg, and she could not walk anymore. CNA 1 stated, Resident 1 used to have one-to-one supervision due to her aggressive behavior like hitting. CNA 1 stated, she was unaware of any interventions being implemented to prevent further resident-to-resident altercations after the one-to-one supervision was discontinued. During an interview, on 6/12/23, at 11:41 a.m., with Director of Nursing (DON), DON stated, when Resident 1 was asked regarding the resident-to-resident altercation happened on 6/8/23, Resident 1 verbalized Resident 2 "was in my things." DON stated, Resident 1 had just been taken off one-to-one supervision the day (6/7/23) prior to the incident due to Resident 1 not having any resident-to-resident altercations. DON stated, Resident 1 was previously on one-to-one supervision due to incidents of resident-to-resident altercations with other residents. DON stated, Resident 1 had episodes of aggressive behaviors like hitting when someone was in her space. During an interview on 6/26/23, at 2:11 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she was assigned to Resident 1 the day (6/8/23) of the resident-to-resident altercation between Resident 1 and Resident 2. LVN 1 stated, Resident 1 had been taken off one-to-one supervision the day (6/7/23) prior to the incident and there was "no witness" to the resident-to-resident altercation between Resident 1 and Resident 2, on 6/8/23. LVN 1 stated, Resident 1 was previously on one-to-one supervision due to her aggressive behaviors of hitting residents, but she was unaware of any other interventions implemented to prevent further resident-to-resident altercations after the one-to-one supervision was discontinued. During an interview on 6/26/23, at 2:24 p.m., with CNA 3, CNA 3 stated, Resident 1 would get physically and verbally aggressive with other residents and the facility would try to avoid resident-to-resident altercations by placing Resident 1 on one-to-one supervision. CNA 3 stated, she was unaware of any other interventions implemented to prevent further resident-to-resident altercations after the one-to-one supervision was discontinued. During an interview on 6/26/23, at 4:27 p.m., with Hospitality Aide (HA) 1 stated, she had been one-to-one supervision with Resident 1 in the past to prevent Resident 1 from getting into physical fights and arguments with other residents. During an interview on 6/26/23, at 4:41 p.m., with HA 2, HA 2 stated, Resident 1 had been one-to-one supervision because when other residents would go by or even look at Resident 1, Resident 1 would become verbally or physically aggressive. During an interview on 6/30/23, at 1:13 p.m., with CNA 2, CNA 2 stated, she was assigned to Resident 1 on the day of the resident-to- resident altercation (6/8/23) between Resident 1 and Resident 2. CNA 2 stated, Resident 1 was in her room, sitting in her wheelchair when CNA 2 went to go check on the breakfast trays. CNA 2 stated, she heard someone speaking loudly and went back to Resident 1's room. When she returned to Resident 1's room, Resident 2 was sitting on the floor and Resident 1 had Resident 2 by the hair and "was shaking" Resident 2's head. CNA 2 stated, when she was separating Resident 1 and Resident 2, Resident 1 kicked Resident 2 on the right side of the leg. CNA 2 stated, no one was watching Resident 1 at the time of the resident-to-resident altercation because Resident 1 was taken off (6/7/23) one-to-one supervision. CNA 2 stated, "any small thing can trigger [Resident 1's behavior] her or if someone is in her way" and she will start fighting. CNA 2 stated, she was unaware of any other interventions being implemented to prevent further resident-to-resident altercations. During an interview on 6/30/23, at 1:25 p.m., with DON, DON stated, no one witnessed the resident-to-resident altercation (6/8/23) between Resident 1 and Resident 2. DON stated, Resident 1 "does not like to stay in her room when she is up in her wheelchair" she should have been where staff could see her at all times according to the care plan. During a review of the facility's policy and procedure (P&P) titled, "Care Plan Revisions Upon Status Change" dated 6/1/22, with the DON, on 7/26/23 at 11:37 a.m., the P&P indicated, "The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. . .Upon identification of a change in status, the nurse will notify the MDS (minimum data set-resident assessment tool) Coordinator, the physician, and the resident representative. . .The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. . .The team meeting discussion will be documented in the nursing progress notes. . . .The care plan will be updated with the new or modified interventions. . .Staff involved in the care of the resident will report resident responses to new or modified interventions." DON stated, staff should have been made aware of Resident 1's care plan interventions. 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 and is a Class A citation.