Health inspection·August 25, 2022

F600 Free from Abuse and Neglect CFR(s): 483.12 (a)(1) §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. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure neglect did not occur for seven Residents (Residents 9, 10, 11, 12, 13, 14, and 15) reviewed by the DOJ (Department of Justice) and abuse did not occur for Resident 8, one of four sampled residents reviewed by this Department (CDPH, California Department of Public Health). 1. The facility failed to ensure there was enough staff to provide ROM (range of motion) services to residents. A DOJ inspection found seven residents (Residents 9, 10, 11, 12, 13, 14, and 15) with documented functional limitations in range of motion and lack of current plans of care related to those limitations. Further investigation by this Department (CDPH) uncovered evidence staff were unable to provide ROM services due to inadequate staffing. Failure to provide ROM services to residents had the potential to lead to contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and decrease mobility for residents with ROM problems . 2. CNA (Certified Nursing Assistant) 5 threw and hit Resident 8 on the face (one of 4 sampled residents) with dirty linen. A reasonable person living in the facility and requiring extensive assistance of staff with care would feel angry, unsafe, anxious, and fearful after having soiled linen thrown in their face. Failure to protect resident 8 from abuse did not ensure all resident were protected from abuse. Findings: 1. Lack of ROM Review of a DOJ subcontractor's emails sent to CDPH on 04/16/2022 at 3:36 PM and 5:01 PM, indicated the DOJ conducted an inspection of the facility from 04/14/2022 to 04/15/2022. During the inspection, the DOJ team identified "Seven of these residents ... had previously documented contractures. All these residents' contractures may have worsened due to no treatment or inadequate treatment." On 04/29/2022 at 12:08 PM, the DON (Director of Nursing) and the Administrator were interviewed regarding the DOJ's ROM findings. The Administrator stated these were mostly documentations issues and she was sure that her staff were providing ROM services. However, statements provided by a family member and three employees regarding staffing shortages and lack of provision of ROM services to residents contradicted the Administrator's conclusion that the DOJ's ROM findings were purely documentation issues. During an interview on 06/16/2022 at 9:12AM, Resident 1's Family Member (RFM1) stated "The staff tell me all the time that they are short and they have to do double (working an extra shift to cover for lack of staffing). The management they don't seem to be hiring much. I used to go there three times a day before the COVID lock down. ... (my mom) used to walk before. But now she doesn't walk. They tell me they have no people to walk her." During an interview on 6/15/22 3:38 PM, CNA 1 stated "Staffing is a problem. We are short. They have registry but it's not enough. ...". When asked about ROM and walking her residents, CNA 1 stated " ...I'm telling you the truth we cannot do it (ROM and walking the resident). There is an RNA (Restorative Nursing Assistant) I don't know what they are doing. They (only work with) specific ...(residents). I'm a CNA it's really hard for me. it's not good. We cannot give the right care. ...". During an interview on 6/15/22 3:59 PM, CNA 2 stated "Most of the time (we are) short of staff, CNA, and nurses we cannot give quality care. ...Mostly... of the time we are short ... ROM and walking the patient the RNA and PT (Physical Therapist) delegate to the CNA we cannot do the ROM ... you need another 8 hours to complete the ROM for... (your) patients with 2 meals. (for) Contracted (residents) it's very hard to work with them 15-20 minutes. Then you have to clean them and give them bed bath it's very hard. There's no time to do ROM. ..." During an interview on 6/15/22 4:14 PM, CNA 3 stated " (I have a lot of) ... (residents) almost every day and I can tell you, how can you give good care to ... (all your residents) in 8 hours. ...". CNA 3 was asked if she can do ROM and walking for her residents. CNA 3 stated "... with ...(my residents), we cannot." Review of a facility's policy titled "Abuse - Prevention, Screening, & Training Program", revised on 6/2022, defined neglect as " ...failure to provide goods and services necessary to attain or maintain physical, mental, and psychosocial well-being, and avoid physical harm, pain, mental anguish, or emotional distress. ...". 2. Resident 8 Review of Resident 8's MDS (Minimum Data Set, a standardized resident assessment tool), dated 05/25/2022, indicated Resident 8 was an elderly female admitted to the facility on 10/08/2020 with multiple diagnoses including : left leg fracture, Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), generalized muscle weakness, history of falls, and anxiety disorder. Resident 8's MDS indicated she required extensive assistance of one staff for bed mobility, transfers, and dressing. Review of a facility letter sent to this Department (CDPH), dated 04/01/2022, indicated " ...On Sunday, March 27, 2022, at around 10:30 AM, the Medical Records Supervisor informed the Administrator that she witnessed a Certified Nursing Assistant (CNA 5) ... hitting ...(Resident 8) with dirty linen. ... According to the Medical Records Supervisor, ... she was near ... (Resident 8's) room when she saw ... (CNA 5) "smack" the resident on the face with soiled linen. ... (based on staff interview, CNA 5) positioned the soiled linen that he was holding and placed it on ...(Resident 8's) face using his right hand .... Based on the investigation, the ... (facility) finds the allegation substantiated due to witness statements. The accused ... (CNA 5) was placed on administrative leave during the investigation and was subsequently terminated." During an interview on 06/30/2022 at 10:15 AM, the MRS (Medical Record Supervisor) stated "I don't remember the exact date. I was in unit 3 with my other staff. On 2nd floor. We were doing the door labeling. Around 9:45 to 10 AM, I heard the resident (from bed 1, Resident 8) started screaming and then I saw ... (CNA 5), he was throwing on her face the soiled cloth and linen from bed 2 to ... (resident 8's) face. ... I told the CNA stop. ...". During an interview on 06/30/2022 at 11:37 AM, Resident 8 was unable to remember or provide any information regarding her interactions with CNA 5 on 03/27/2022. Resident 8 has a diagnosis of Alzheimer's disease and Alzheimer's disease does affect a patient's memory and how they think. However, a reasonable person (with no diagnosis of Alzheimer's and no mental deficits) living in the facility and requiring extensive assistance of staff with care would feel angry, unsafe, anxious, and fearful after having soiled linen thrown in their face. During an interview on 06/30/2022 at 10:38 AM, the Assistant Administrator (AA) stated "QA (Quality Assurance Department) has looked at this (abuse) issue. The initial part would be an IDT meeting (Inter-disciplinary Team, a team consisting of health care professionals from various fields) so that we can create immediate interventions." Facility failed to analyze root cause of the abuse and implement systemic changes to prevent abuse During an interview on 06/30/2022 at 1:10 PM, the QA (Quality Assurance) nurse stated she was involved in abuse cases "as soon as possible". The QA nurse stated part of her job was to ensure all documentations were done regarding abuse cases. The QA nurse stated in general it would take one to two weeks to do a root cause analysis of an abuse case. The QA nurse was able to identify staffing problems, staff burn out, inadequate monitoring of direct care staff by supervisors, and abuse/neglect training as potential systemic issues that could lead to abuse. The QA nurse was asked to provide documented evidence of a root cause analysis of Resident 8's abuse, back on 03/27/2022 (almost 95 days ago) and documented evidence the facility has implemented systemic changes to prevent abuse. The QA nurse was unable to provide the requested documents. The facility knew another resident made an allegation of abuse against CNA 5 (see F867) back in 04/18/2021. The facility was unable to provide documented evidence CNA 5 was under increased supervisory monitoring after the allegation. The facility was unable to provide documented evidence there was regular monitoring of residents under CNA 5's care for evidence of abuse/neglect when CNA 5 returned to his regular duties after the 04/18/2021 abuse allegation investigation. Review of a facility policy titled "Abuse - Prevention, Screening, & Training Program", revised on 6/2022, indicated "The facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. The facility develops policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The Administrator as the Abuse Prevention Coordinator, is responsible for the coordination and implementation of the facility's abuse prevention, screening, and training program policies and procedures. ...".