Health inspection·July 12, 2022

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident # CA00782496. Event ID: 7RP711. Representing the Department, HFEN #36087. State Citation B was written. §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. 22 CCR § 72527 (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. On 4/28/22 at 11:35 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident of resident to resident physical abuse. On 4/22/22 at 12 p.m., Resident 1 was moved within the facility to share a room with Resident 2. On 4/22/22, Resident 2 struck a staff member; no changes were made in Resident 2's care plan, and Resident 1 continued to share a room with Resident 2. On 4/27/22, "around noon" a certified nursing assistant entered the shared room of Resident 1 and Resident 2 and found Resident 1 in bed, bleeding from a head wound. The certified nursing assistant left Resident 1's bedside to call for assistance and when the certified nursing assistant returned to Resident 1's bedside, Resident 2 was standing over Resident 1 holding a quad cane (a device used for walking that has a metal base on the bottom with four small feet that extend from the base) in the air above Resident 1. Resident 1 was sent to the hospital; the hospital After Visit Summary indicated Resident 1 had a scalp laceration which required closure with two staples. The facility failed to protect Resident 1, a dependent resident unable to protect himself from physical abuse by: 1. Continuing to room Resident 1 with Resident 2, after Resident 2 demonstrated physical aggression to others, and 2. Leaving the bedside of Resident 1 after he was first assaulted. A review of Resident 1's Face Sheet, undated, indicated Resident 1 was admitted to the facility in 2015 with diagnoses of cerebrovascular disease (impaired blood flow to the brain) and adult failure to thrive (a state of decline resulting in weight loss, depression, and decreasing functional ability). A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/1/22, indicated Resident 1 had unclear speech, was usually understood, and sometimes understood others. The MDS indicated Resident 1 was impaired on both upper and lower extremities, on one side of his body. The MDS indicated Resident 1 required extensive assistance from one person for bed mobility, dressing, and personal hygiene; total assistance from one person for locomotion; and total assistance from two people for transfer between surfaces. The MDS indicated Resident 1 used a wheelchair for locomotion. A review of Resident 2's Face Sheet indicated Resident 2 was originally admitted to the facility in February 2021 with a diagnosis of a mental disorder causing disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions. A review of Resident 2's MDS dated 4/10/22, indicated Resident 2 had unclear speech, was usually understood, and usually understood others. The MDS indicated Resident 2 used a walker or wheelchair for locomotion, and was not steady, but was able to stabilize himself without staff assistance. The MDS indicated Resident 2 had no impairment to either upper or lower extremities. A review of Resident 2's care plan dated 8/26/21, for the problem of negative behavioral symptoms of rejection of care, wandering, and physical abuse to others, indicated a goal of Resident 2 having more productive and meaningful activity and less negative behavioral symptoms occurrence. Interventions to achieve the goals included: observe for pain/discomfort that might trigger negative behavior; remove from triggering environment to a calm and quiet place with supervision; and monitor for behavior not easily altered. A review of Resident 2's care plan, dated 4/22/22, indicated a problem of physical aggression: Resident 2 hit a staff member in the neck on 4/22/22. The care plan indicated a goal of Resident 2 displacing physical aggression to meaningful activities. Interventions to achieve the goals included: coach and train resident to respond assertively rather than aggressively; develop behavioral management plans that include rules, expectations, and consequences and implement consistently; and enhance feeling of self-control by assisting in identifying available resources and personal strengths. A review of the facility form, "Notification of Room Change," dated 4/22/22, indicated Resident 1 was relocated in the facility to share a room with Resident 2 on 4/22/22 at 12 noon. A review of Resident 1's clinical record titled, "Situation, Background, Assessment, Recommendation (SBAR) - General," dated 4/27/22, indicated Resident 2 stated he had hit his roommate Resident 1, with a quad cane (a cane with four short legs on the base) for no apparent reason. The SBAR indicated Resident 1 was transferred to the hospital via 9-1-1 for treatment. During an interview on 4/28/22, at 12:37 p.m., with the Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she had been working yesterday around noon when she saw Resident 2 standing in the hall next to the entry to his room. CNA 1 stated Resident 2 asked her to call 9-1-1 (emergency call) because he wanted food. CNA 1 stated she had entered the shared room of Resident 1 and 2, to do a routine check of Resident 1, and saw Resident 1 in bed with blood "rolling down" from his forehead to his nose. CNA 1 stated she went outside the shared room to call Licensed Vocational Nurse 1 (LVN 1) for help, and when she turned back around CNA 1 saw Resident 2 standing next to Resident 1's bed, holding a quad cane up in the air. CNA 1 stated she took the cane away from Resident 2. During an interview on 4/28/22, at 1:30 p.m., with LVN 1, LVN 1 stated he was at the nursing station next to the shared room of Resident 1 and 2, when CNA 1 called for him. LVN 1 stated he entered the shared room of Resident 1 and 2 and saw Resident 1 lying in bed, swearing, and bleeding from his head. LVN 1 stated 9-1-1 was called and Resident 1 went to the acute care hospital. A review of Resident 1's " Emergency Department (ED) Provider Notes, After Visit Summary," dated 4/27/22, the Notes indicated Resident 1 obtained a scalp laceration which required two staples to close. The Notes indicated Resident 1 would require physician follow-up for removal of the sutures in five to seven days. During an observation and concurrent interview on 5/5/22, at 2:15 p.m., with Resident 1, Resident 1 had two staples on top of a black colored oblong scab (approximately one inch by 1/2 inch) on the top of his head. Resident 1 did not respond when asked how he obtained the injury to his head. During an interview on 4/28/22, at 11:35 a.m., with the Director of Nursing (DON), the DON stated the Interdisciplinary Team (IDT, professionals from various disciplines within the facility, who discuss treatment plans for resident care) had daily discussions about resident room assignments. The DON stated IDT considered residents' behaviors and potential compatibility when deciding on room assignments. The DON was unable to provide documentation that indicated an IDT discussion occurred for the decision to assign Resident 1 to Resident 2's room. During an interview with Resident 2 on 4/28/22, at 1:47 p.m., Resident 2 sat in a wheelchair, with a staff member seated within arm's reach from Resident 2. Resident 2 stated he had hit Resident 1's head three times with a hammer because Resident 1 lied to him about Resident 1's life. A review of the facility policy and procedure titled, "Abuse and Neglect Prohibition," dated October 2004, indicated, "Each resident has the right to be free from mistreatment, neglect, abuse..." The facility failed to protect Resident 1, a dependent resident unable to protect himself from physical abuse by: 1. Continuing to room Resident 1 with Resident 2 after Resident 1 demonstrated physical aggression to others, and 2. Leaving the bedside of Resident 1 after he was assaulted. The above violations either jointly or separately have a direct or immediate relationship to patient health, safety or security.