Other·February 7, 2023

The following reflects the findings of the California Department of Public Health during the investigation of a Complaint investigated during the Recertification Survey. CFR §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. CFR §483.12(a) The facility must- CFR §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion On 10/17/22, at 12:00 PM, an unannounced visit was conducted at the facility to investigate a complaint about two residents constantly fighting with each other and the facility had not intervened. The facility admitted Resident 23, a 79-year-old female, on 10/24/17. Resident 23 diagnoses included: a history of stroke (damage to tissues in the brain due to a loss of oxygen) with left-sided weakness and schizophrenia (mental disorder affects a person's ability to think feel and behave clearly) with documented verbally aggressive behaviors. Resident 23 had a Brief Interview for Mental Status (BIMS, evaluates aspects of cognition, a score of 13-15 indicates cognitively intact, 8 to 12 moderate impairment, and 0 to 7 severe impairment) score of 3. Resident displayed behaviors of unprovoked yelling, striking out during care and refusal of care. The facility admitted Resident 6, a 79-year-old female, on 5/1/22. Resident 6 had a care plan for anxiety (worry or fear of everyday situations). Resident 6 had a BIMS score of 99 indicating the facility was unable to assess the cognitive function of Resident 6. Based on observation, interview, and record review, the facility failed to ensure five of five sampled residents (Resident 3, Resident 6, Resident 23, Resident 39 and Resident 51) were free from verbal abuse, when Resident 6 and Resident 23 repeatedly yelled/screamed at each other. This failure likely caused Resident 3, Resident 6, Resident 23, Resident 39, and Resident 51 significant humiliation, indignity, anxiety other emotional psycho-social trauma. During an observation on 10/17/22, at 3:56 PM, outside of Resident 6 and Resident 23's shared room, voices yelling "shut up" were heard through the closed door. During an observation on 10/18/22, at 8:36 AM, inside Resident 6 and Resident 23's shared room, Resident 6 (in the "B" bed) was screaming at Resident 23 (in the "C" bed), "You have the face of a bitch, just kill yourself! You are a bastard!" Resident 23 replied to Resident 6, "Stop bothering me!" Resident 6 then said, "Shut up, your ugly face bothers you!" During this exchange, uniformed staff were observed walking past room without intervening. During an observation on 10/18/22, at 10:12 AM, inside Resident 6 and Resident 23's shared room, with the door opened, Resident 23 asked for her mother. Resident 6 screamed, "Your mother's dead!" Resident 23 began to cry, with tears noted on her cheek. Uniformed staff came into Resident 6 and Resident 23's shared room, looking for a walker, then walked out without intervening. Two other uniformed staff members were noted walking by the open door to Resident 6 and Resident 23's shared room, without intervening. During an interview on 10/18/22, at 11:50 AM, with the Social Services Manager (SSM). SSM stated, Resident 3 was in the "A" bed of Resident 6 and Resident 23's room and had been moved out of that room on 10/14/22, because of the noise from "voices." SSM stated, Resident 3 insisted on moving out of the shared room, even though her mother had just paid "a lot of money" to install a telephone in the room. During an interview on 10/19/22, at 7:51 AM, with Licensed Vocational Nurse, (LVN) 1, LVN 1 stated, there had been issues between Resident 23 and Resident 6, with the two of them yelling at each other and calling each other names. LVN 1 stated, "Yeah, it has happened before. It's been on and off for the past couple of months." LVN 1 stated, the Director of Nursing (DON) and SSM "are aware." During an interview on 10/19/22, at 3:03 PM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated, she would often hear Resident 6 and Resident 23 yelling back and forth at each other. CNA 2 stated, she let the nurses know but they "didn't do much." CNA 2 stated, "I would try to redirect them [Resident 6 and Resident 23]. [Resident 3 (formerly in the shared room with Resident 6 and Resident 23)] would complain and tell them to shut up, so they [the facility] moved her. They [Resident 6 and Resident 23] cry and yell a lot, all the time." During an interview on 10/19/22, at 3:10 PM, with Resident 51, Resident 51 stated, Resident 6 and Resident 23 "Holler too much. That [Resident 6] is just mean, always yelling stuff like your momma's a whore and stuff like that. She is evil, [Resident 23] is always crying!" Resident 51 stated, "She has been doing this for about 3 months. I can't rest." During an interview on 10/19/22, at 3:11 PM, with Resident 39, Resident 39 stated, "We tell the staff all the time [about Resident 6 and Resident 23 yelling at each other] and they just say, 'if you want to find a room for her, then go ahead.' I'm glad they finally moved [Resident 23], maybe I can get some sleep now." During an interview on 10/20/22, at 3:04 PM, with Activities Assistant (AA), AA stated, "Resident 6 and Resident 23 yell at each other back and forth." AA stated, they would "antagonize" each other all the time, and "I told the nurse." During an interview on 10/20/22, at 3:49 PM, with CNA 3, CNA 3 stated, "When I worked on the opposite side, I would hear them [Resident 6 and Resident 23] being vulgar and demeaning to each other all the time when I would work. Just being really ugly, you know?" CNA 3 stated, he reported it once to his charge nurse, "I believe I reported it, like two weeks ago." During a review of Resident 6's Care Plan for anxiety, dated 10/5/22, the Care Plan indicated, "busPIRone HCL" (medication for anxiety) 7.5 milligrams (unit of measurement) one tablet two times a day for anxiety related to "unprovoked yelling/screaming." During a review of Resident 6's Medication Administration Record (MAR), dated 10/1/22 through 10/31/22, the MAR indicated, on: 10/12/22 Resident 6 had 4 instances of anxiety; 10/13/22 Resident 6 had 4 instances of anxiety; 10/14/22 Resident 6 had 3 instances of anxiety; 10/15/22 Resident 6 had 4 instances of anxiety; 10/16/22 Resident 6 had 4 instances of anxiety; 10/17/22 Resident 6 had 3 instances of anxiety; 10/18/22 Resident 6 had 4 instances of anxiety; 10/19/22 Resident 6 had 4 instances of anxiety; and 10/20/22 Resident 6 had 4 instances of anxiety. During an interview on 10/24/22, at 10:45 AM, with Registered Nurse (RN) 1, RN 1 stated, she would hear Resident 6 and Resident 23 yelling at each other "on and off" for the last "2 or 3 weeks." During a review of the facility's policy and procedure titled, "Abuse Reporting and Investigation," dated 6/21, the policy indicated, "The Abuse Coordinator will provide a safe environment for the resident as indicated by the situation. If the suspected perpetrator is another resident, separate the residents so they do not interact with each other until the circumstances of the reported incident can be clarified." Conclusion: In violation of the above cited standards, the facility failed to intervene in the verbally abusive relationship between Resident 6 and Resident 23 resulting in ongoing verbal abuse to Resident 6, Resident 3, Resident 39, and Resident 51 and required a physician order for an anti-anxiety medication for Resident 6. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents. Page 2 of 2