Health inspection·August 15, 2024

42 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. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 42 CFR § 483.12 - Freedom from Abuse, Neglect, and Exploitation (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95. 42 CFR § 483.21. Comprehensive Care Plans (b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and 72311 - Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. 72311 - Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. 72311 - Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. 72315 - Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 72527 - Patients' Rights (a) Patients have the rights enumerated in this section and that facility shall ensure that these rights are not violated. The facility shall establish and implement written polices 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. Findings On 6/13/2024 at 9:50 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident of patient-to-patient abuse. As a result of the investigation, the Department determined that the facility failed to: Ensure Patient 1 was free from physical abuse when he was assaulted by Patient 2. Implement the facility's patient abuse and neglect policy and procedure (P&P) when Patient 2 hit Patient 1 in the face. Consistently assess, monitor, and update care plan interventions, in accordance with the facility's P&P, when Patient 2 who had a history of being a danger to others (DTO), difficulty adjusting to changes and unpredictable behaviors moved to roommate with Patient 1. Due to these failures, on 6/10/2024 at approximately 4:00 a.m., Patient 2 hit Patient 1's face, in their room. Patient 1 suffered multiple facial injuries that included a nasal bone fracture. These injuries resulted in harm to Patient 1 that required the patient to be transferred to the Emergency Room (ER) for medical evaluation. Patient 1's clinical record documented that he was admitted to the facility on 6/21/2018 with diagnoses that included: an unspecified neurocognitive disorder (decreased mental function due to a medical disease other than psychiatric illness), unspecified displaced fracture of second cervical vertebra (break in the second bone of the neck), an aneurysm (a ballooning and weakened area in an artery) of the vertebral artery, and tracheostomy (A hole made by surgeons into the throat to help with breathing). Patient 1 had cognitive impairments that affected his ability to think and recall information, as well as left him non-verbal and non-ambulatory. Patient 2's clinical record documented that he was admitted to the facility on 4/11/2018 with diagnoses that included: major neurocognitive disorder due to probable fronto temporal degeneration (brain damage), with behavioral disturbance, and unsteadiness on feet. Patient 2 had a history of behaviors that included DTO. A review of the document titled, "Minimum Data Set" (MDS, A standardized assessment tool that measures health status), dated 5/4/2024, indicated Patient 1 was non-verbal, was rarely able to express ideas and wants, and rarely understood others. The record indicated staff assessed that Patient 1 had short-term and long-term memory problems, and severe cognitive impairment. The MDS further indicated that Patient 1 had no identifiable behavioral issues. A review of the document titled, "Treatment Plan," dated 5/22/2024, indicated that Patient 2 had poor verbal communication that resulted in violent behavior towards peers and staff. Record further indicated that Patient 2 had "...multiple allegations of threatening and assaulting other patients." Further review of the document titled, "Treatment Plan," dated 5/22/2024, indicated Patient 2 had an active Focus #3.1 for Dangerousness and Impulsivity (a care plan for behaviors related to dangerousness and impulsivity). The objective was that Patient 2 would practice positive coping skills 2x a day as measured by staff observation and self-report to decrease violent behavior. There were no documented interventions in Patient 2's treatment plan to show the facility consistently assessed the patient's behaviors and updated the care plan interventions for dangerousness and impulsivity towards others. A review of the document titled, "Treatment Plan," dated 5/31/2024, indicated Patient 1 was non-verbal, medically compromised and bedridden.A review of the document titled, "Physician's Orders," dated 6/10/2024 at 4:45 a.m., indicated the physician ordered Patient 1 to be transferred to the ER via paramedics "...for evaluation... assault with facial injuries." A review of the document titled, "Physician Note: Transfer to Outside Facility for Emergency or Other Services," dated 6/10/2024, indicated Patient 1 was being transferred to higher level of care due to "s/p [status post] assault c/o [complaint of] facial bleed and bleeding from tracheostomy." Record indicated Patient 1 was assaulted by another patient and sustained multiple facial injuries and had noticeable bleeding from nose, mouth, eye, and tracheostomy site. A review of the document titled "Physician Progress Notes," dated 6/10/2024 at 5:10 a.m., indicated "... since unit population is vulnerable patient [Patient 2] may harm himself indirectly or may cause further danger to others." A review of the document titled, "Physician Progress Notes," dated 6/10/2024 at 8:20 a.m., indicated that when Patient 2 was asked about the incidents and motive, Patient 2 was not able to recall or provide a motive and stated, "I don't know." A review of the document titled, "Interdisciplinary Notes" (IDN), dated 6/10/2024 at 8:21 a.m., indicated that Patient 1 was assaulted by Patient 2. Patient 2 was observed to have bloodied hands and blanket. Patient 2 refused assessment by staff. A review of the document titled, "Return from Outside Hospitalization Note," dated 6/13/2024, indicated upon readmission to the facility, Patient 1 had "...multiple abrasions on face, with bilateral periorbital [surrounding the socket of the eye] edema [swelling] and purplish discoloration. Nasal abrasions noted." The record also indicated that Patient 1 had a CT Maxillofacial (an imaging procedure that uses x-ray and computer to create cross-sectional images of the face, mouth and jaw) scan which showed Patient 1 sustained a comminuted (bone broken in at least two places) nasal bone fracture. During an observation on 6/20/2024 at 10:57 a.m., in Patient 1's room, multiple facial discolorations were observed on Patient 1. A green and yellow discoloration was observed next to Patient 1's right eye and a reddish/purple discoloration was observed underneath Patient 1's right eye. A light reddish/purple discoloration was observed under Patient 1's left eye. A slight greenish/yellow discoloration was observed around the bridge of Patient 1's nose. Patient 1 was bedridden, dependent on staff for all activities of daily living (ADLs; bed mobility, transfer, toileting, etc) and had a tracheostomy in place. During an interview on 6/20/2024 at 12:31 p.m., Clinical Social Worker (CSW) stated Patient 2 was very impulsive, got irritated easily and had a history of low frustration, difficulty adjusting to changes and DTO. CSW stated Patient 2 had recently moved rooms and was roomed with Patient 1 due to a Covid quarantine on the unit. During an interview on 7/2/2024 at 11:46 p.m., Registered Nurse (RN) 2 stated on 6/10/2024 at approximately 4:00 a.m., he was conducting every 30-minute safety checks and entered the Patient 's room [Patient 1 and Patient 2's room]. RN 2 stated he observed blood all over Patient 1's face. Patient 1 had multiple facial contusions and lacerations. RN 2 further stated he observed Patient 2's hands and blanket covered in blood. RN 2 stated the physician ordered Patient 1 to be transferred to the hospital for evaluation. As the interview continued with RN 2, RN 2 stated that Patient 2 had an extensive history of DTO, especially with his peers. RN 2 also stated that Patient 2 was very strong, even though he needs a wheelchair for ambulation, he was still able to stand himself up and shuffle a few steps. RN 2 stated Patient 2's behaviors were unpredictable; he would be calm one moment and aggressive the next. Furthermore, RN 2 stated Patient 1 was not capable of provoking or defending himself as he was non-verbal and non-ambulatory. Despite observations by CSW and RN 2 that Patient 2 had difficulty adjusting to changes, and had a recent room change, poor communication with others, and his behavior was unpredictable, there were no documented updated care plan interventions addressing Patient 2's DTO. Review of the facility's P&P titled, "Reporting Patient Abuse and Neglect," dated 5/26/2023, indicated, "Abuse or neglect of patients is not condoned and shall not be tolerated..." The P&P also indicated that "...Physical Abuse: Any of the following: (a) Assault, as defined in Section 240 of the Penal Code." Review of the facility's P&P titled, "Treatment Plan," dated 8/31/2022, indicated, "...3.1 Treatment Plan (TxP)... is developed by an interdisciplinary team... It documents focus of treatment, an intervention plan..." The P&P further indicated "...5.1 The TxP is: ... 5.1.5 Identifies foci of treatment, objectives, and interventions... 5.1.7. Ensures that there are interventions that relate to each objective..." The facility failed to: Ensure Patient 1 was free from physical abuse when he was assaulted by Patient 2. Implement the facility's patient abuse and neglect policy and procedure (P&P) when Patient 2 hit Patient 1 in the face. Consistently assess, monitor, and update care plan interventions, in accordance with the facility's P&P, when Patient 2 who had a history of being a danger to others (DTO), difficulty adjusting to changes and unpredictable behaviors moved to roommate with Patient 1. Due to these failures, on 6/10/2024 at approximately 4:00 a.m., Patient 2 hit Patient 1's face, in their room. Patient 1 suffered multiple facial injuries that included a nasal bone fracture. These injuries resulted in harm to Patient 1 that required the patient to be transferred to the ER for medical evaluation. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.