Health inspection·September 27, 2024

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 protect one of three sampled residents (Resident 1) from sexual abuse when Resident 2 climbed into Resident 1's bed and kissed him on the lips. This failure resulted in Resident 1 not being able to sleep well due to feeling unsafe at the facility. Findings: A review of the facility policy titled "ABUSE AND NEGLECT PREVENTION, IDENTIFICATION, INVESTIGATION, PROTECTION, REPORTING AND RESPONSE", last revised on 11/14/23, indicated that sexual abuse is defined as "non-consensual sexual contact of any type with a resident." One of the stated purposes of the policy is to "provide clinical interventions to prevent and minimize abuse or neglect ..." The policy further indicated that "In cases of allegations of abuse ... or resident-to-resident or visitor-to-resident altercation, the nurse manager or charge nurse, with input from the RCT [Resident Care Team, a collaborative group of people involved in a resident's care] and the resident(s) themselves (If possible) shall take the lead in assessing and updating the residents care plan(s). Considerations for care planning may include the following ...staff action and/or inaction that may have contributed to the resident's behavior ... Ability to modify environment ... Likelihood of repeat incident ... Interventions to minimize the risk of recurrence." A review of the facility policy titled "COACH [a person assigned to a resident for close supervision] USE FOR CLOSE OBSERVATION", last revised in 10/10/23, indicated that "Resident behaviors that may require close observation include but are not limited to the following: harm to self or others ... Other extenuating needs as determined by the Resident Care Team (RCT) and with the approval of Nursing Director/Nursing Operations." The facility policy further indicated that the "RCT (at a minimum, the MD and RN) shall review the resident's condition, the specific behaviors that need intervention, and the close observation measures needed to ensure resident safety ... if no progress is made, resident case may be referred to clinical leadership for long term placement." A review of Resident 1's history and physical (a formal and complete assessment of someone done by a medical provider), dated 03/09/21, indicated that Resident 1 "doesn't have capacity to make medical decisions. Patient has a probate conservator [someone appointed by a court to act on behalf of someone that is no longer able to handle their own financial and/or personal affairs]" A review of Resident 1's annual Minimum Data Set (MDS, a resident assessment tool), dated 02/14/24, indicated that Resident 1 was admitted in 2020 with diagnoses including stroke (when blood flow to the brain is stopped due to bleeding or a blockage in blood flow) and aphasia (difficulty in communicating). The MDS also indicated that the Brief Interview for Mental Status (BIMS, a cognitive screening tool) was unable to be completed by Resident 1. In turn, a staff assessment for mental status was done for Resident 1 and his "Cognitive skills [brain functions] for daily decision making" was assessed as "moderately impaired". A review of Resident 2's quarterly MDS, dated 04/17/24, indicated that Resident 2 was admitted in 2016 with diagnoses including stroke and hypertension (high pressure in the vessels that carry blood). The MDS further indicated that Resident 2 has a BIMS score of 15 (scores of 0-7 suggest severe cognitive impairment, 9 to 12 suggests moderate cognitive impairment, and 13 to 15 suggest that cognition is intact). A review of Resident 2's RCT note, finalized on 08/07/19, indicated that Resident 2 is "assigned a coach for multiple incidents of inappropriately touching vulnerable residents ... However most recent incident Occurred in the unit and was deemed by RCT to assign resident his own COACH 24h [hours]." A review of Resident 2's RCT note, finalized on 08/04/20, indicated that Resident 2 is "assigned a coach for multiple incidents of inappropriately touching vulnerable residents ...Resident [2] has also demonstrated intentionally trying to shake off his coach or leave assigned staff behind in order to approach other male residents. For these reasons we will continue with 24 hours COACH supervision at this time." A review of Resident 2's history and physical, dated 09/13/21, indicated that Resident 2 "has repeated history of inappropriate verbal and physical behaviors, including intrusiveness [violating someone's personal space or privacy], sexual misconduct (touching others without consent, public masturbation, sex acts with others), verbal aggression ... Due to repeated behaviors, starting in July 2018, [Resident 2] must be accompanied with a coach whenever he goes off unit. Then in August 2019 he was assigned a 24 hr [hour] coach." A review of a nursing note for Resident 2 written by Registered Nurse (RN) 1, dated 09/20/21, indicated that "This writer reminded [Resident2] of the reasons why he has coach ... This writer explained to him [Resident 2] that he has not demonstrated that other residents are safe around [him] and that's why we are continuing with a COACH at this timet [sic]". A review of Resident 2's RCT note, finalized 08/25/22, indicated that "resident continues to requires [sic] 1:1 [one-to-one, someone is assigned to supervise only one person] supervision across 3 shift due to multiple history [sic] of sexually inappropriate behavior towards vulnerable residents in and out of the unit. Resident continues to not realize why his action [sic] are wrong and still tries to find opportunities to approach residents that he had history of inappropriate contact with." A review of Resident 2's RCT note, finalized 06/24/23, indicated that "Resident [2] is provided 24/7 days/week [sic] coach due to multiple history [sic] of sexually abusing vulnerable residents in the past. He continues to present this risk and 24 hour supervision is necessary." During a concurrent interview and record review on 05/01/24 at 12:11 PM with Charge Nurse (CN) 1, Resident 2's nursing note written by RN 3, dated 04/16/24, was reviewed. CN 1 stated they are the charge nurse for the Behavioral Response Team (BRT) and RN 3 is a BRT nurse. CN 1 explained that the BRT is part of the therapeutic care team which supports "the resident and staff member to create a therapeutic care environment." CN 1 stated that the BRT often works with residents with "agitation [a state of nervous anxiety or excitement]" and residents with "verbal or physically aggressive behavior." The nursing note indicated that RN 3 "checked in with unit charge nurse ... who reported resident's verbally inappropriate behavior towards co-residents has declined due to the 1:1 assist staff interventions for redirecting and setting boundaries with resident." Based on this note, CN 1 stated that the one-to-one supervision is "helping control his [Resident 2's] behavior." CN 1 further stated that the BRT does not decide if someone should have a coach because the RCT should decide. She stated that the RCT knows the resident better and the BRT is "not in the unit all the time." A review of Resident 2's RCT note, finalized on 04/23/24, indicated that "Resident remains on 1:1 staff supervision due to continued behaviors of impulsivity [tendency to act without thinking] and inappropriate behavior." A review of Resident 2's Care Plan Addendum (update or correction to a care plan), dated 04/25/24, indicated that "care plan updated to reflect reduction of 1:1 staff supervision". The care plan further indicated that Resident 2 has "episodes of verbally aggressive behavior ...cursing at staff when he is prevented from doing things that may be deemed harmful to his peers (such as sexually explicit acts or conversations, teasing) or himself ... Has history of sexually inappropriate behaviors which include physical sexual contact such as kissing another resident, inappropriate conversations, exposing himself in a public place". The care plan further indicated an intervention of "Continue 1:1 coach 16 hours a day (DAY [7:00 AM to 3:00 PM], PM [3:00 PM to 11:00 PM])". A review of a nursing note for Resident 2 written by Registered Nurse Manager (RNM) 1, dated 04/25/24, indicated that Resident 2's "1:1 staff supervision was reduced to Day and PM shift. Resident will no longer have a 1:1 staff during the AM [11:00 PM to 7:00 AM] shift." A review of nursing note for Resident 2 written by RN 4, dated 04/26/24 at 7:04 AM, indicated that Resident 2 "continues with 1:1 supervision for safety. Continues to propelled [sic] (move) self via [through use of] wheelchair in and out of his room to the great room." A review of Resident 2's RCT note, finalized 04/26/24 at 1:21 PM, indicated that "Resident started on 04/26/24 AM with the reduction and will remain with 1:1 staff on DAY and PM shift." A review of a nursing note for Resident 2 written by RN 4, dated 04/29/24, indicated that "At 0510 [5:10 AM] resident [Resident 2] observed not in his room. Staff immediately searched [for] resident and was found sitting on resident [Resident 1's] bed kissing each other. Both residents had clothes on and smiling ... Separated both resident right away ... Assigned 1:1 supervision [to Resident 2] for safety due to inappropriate sexual behavior." A review of a Social Worker [a professional trained to help people enhance social functioning and cope with problems of everyday living] note for Resident 2 written by Social Worker (SW) 1, dated 04/29/24, indicated that "He [Resident 2] stated that he is physically attracted to his peer ... 'I need to focus to do something that interest me. (Name of the peer) is my target." A review of a facility report sent to the California Department of Public Health titled, "REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE", dated 04/29/24, indicated that "When asked if he [Resident 1] felt safe, [Resident 1] shook his head, 'no'. When asked why he did not feel safe, res [resident] shrugged his shoulders as if to say he didn't know." During an interview on 04/30/24 at 10:49 AM with RN 4, RN 4 stated that she was the nurse that witnessed Resident 2 kissing Resident 1 on Resident 1's bed on 04/29/24. RN 4 stated that Resident 2 did not have a coach at the time of the incident because it was "stopped" for her shift. RN 4 stated that the presence of the coach has "been effective ... he hasn't had any inappropriate sexual behavior," when the coach is present. RN 4 further stated that the coach was important because Resident 2 is "very smart ... he knows when nobody is there" and will act inappropriately when staff is not present. RN 4 also stated that she was not included in the decision to discontinue the coach for Resident 2 on her shift. During an interview on 04/30/24 at 11:11 AM with Resident 1, Resident 1 was asked if someone was bothering him; Resident 1 responded, "Yeah." When asked if it was another resident, Resident 1 stated, "Yeah." When asked if another resident is hurting him, Resident 1 stated, "Yeah" and proceeded to point to his lips. When asked if this touch bothered him, Resident 1 stated, "Yeah." When asked if he saw that resident today, Resident 1 stated, "No." When asked if he saw the resident yesterday (04/29/24), Resident 1 stated, "Yeah." When asked if Resident 1 feels safe, resident shook his head left-to-right. When asked if the reason he doesn't feel safe is because of the person that touched him, Resident 1 stated, "Yes." When asked if he is able to sleep okay, Resident 1 stated, "No". When asked if the reason he is unable to sleep is because of his safety concern, Resident 1 stated, "Yeah." During an interview on 04/30/24 at 1:40 PM with Resident 2, Resident 2 was asked about Resident 1. Resident 2 stated "I am physically attracted to him [Resident 1] ... I go to him". Resident 2 stated that he recalled kissing Resident 1 "early in the morning yesterday [04/29/24]". Resident 2 further stated that the incident occurred "about 5 o'clock in the morning." During an interview on 04/30/24 at 2:17 PM with Patient Care Assistant (PCA) 1, PCA 1 stated that she works as a PCA for Resident 2. PCA 1 also stated she has been working on this unit for about a year and is familiar with Resident 2's care. When asked about the importance of the coach for Resident 2, PCA 1 stated, "He knows ... he's very smart ... he knows that somebody is watching him ... If there is no coach he can go everywhere. Even at night ... He is up and down in bed ... you think he's sleeping and then he's up." PCA 1 further stated that "once he [Resident 2] knows he has a coach, he will not go," to other residents' rooms. When PCA 1 was asked if she was aware of any other intervention that has been helpful in preventing Resident 2's sexually inappropriate behavior, PCA 1 stated, "Only that one [a one-to-one coach] because he's smart." During an interview on 04/30/24 at 2:49 PM with RNM 1, RNM 1 stated that Resident 2 had a coach for "inappropriate sexual behavior." When asked who was part of the decision to reduce Resident 2's coach time, RNM 1 stated the instruction came "from leadership." RNM 1 stated that the decision did not come from Resident 2's RCT. During an interview on 04/30/24 at 2:52 PM with Nursing Supervisor (NS) 1, NS 1 stated that the decision to reduce the coach for Resident 2 was made by a committee that looked to "verify if coaches are needed for every shift." NS 1 verified that no clinical staff from Resident 2's unit was consulted about coach reduction. NS 1 stated he was just notified by the committee about the reduction in coaching hours and stated, "I was made aware that was what had to happen." NS 1 further added, "If it were up to us on the unit, we would not have reduced it [Resident 2's coach]." NS 1 stated that from his understanding, the basis for discontinuation was that about "90% of the time it showed that [Resident 2] was sleeping over the night." When asked what interventions have been shown to be effective in preventing Resident 2's sexually inappropriate behavior, NS 1 stated, "we moved his household [moved to a different hallway of the unit] and the round the clock coach. Those worked." As outlined in the findings, Resident 1 was assessed as having moderately impaired cognitive skills and therefore the state agency has applied the reasonable person concept in determining the psychosocial outcome for this deficiency. This violation had a direct or immediate relationship to the health, safety, or security of residents.