Health inspection·May 29, 2024

The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a Facility Reported Incident CA00888801 and complaint CA00891006. Event ID: DR6E11 Exit date: 5/2/24 Representing the Department: 44733, Health Facilities Evaluator Nurse 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. On 5/2/24, an unannounced visit was conducted at the facility to investigate Facility Reported Incident and complaint regarding Resident Abuse. The facility failed to ensure residents were from physical abuse when Resident 2 hit Resident 1 in the face, causing injury to Resident 1's above the eyebrow area and first aid being administered. Resident 2's act of hitting Resident 1 in the face was deliberate act to inflict harm or injury, not accidental; therefore, his action was deemed a willful act and considered abuse. This failure had the potential to cause both physical and emotional harm to all residents. On 3/8/24, the facility submitted a facsimile (FAX, a telephonic transmission of scanned printed material) to the California Department of Public Health (CDPH) about a physical altercation between residents. The FAX indicated residents were observed in a physical altercation, and first aid was rendered to victim (Resident 1)'s skin tear on the right eye. Review of Resident 1's clinical record indicated he was admitted to the facility on 3/23/20 with diagnoses including dementia (changes to memory, thinking, and behavior, decline in thinking skills), paranoid personality disorder (a mental health condition marked by a pattern of distrust and suspicion of others without adequate reason), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear). Resident 1's Minimum Data Set (MDS, an assessment tool) dated 12/16/23 indicated a Brief Interview for Mental Status (BIMS) score of 11 (mild impaired cognition). Review of Resident 1's care plans indicated a plan to address an allegation of abuse, resident to resident altercation with injury: skin tear to the right lateral orbital area (the cavity of the skull in which the eyeballs are situated). The interventions included assessing the resident for injuries and rendering care promptly. Review of Resident 1's Interdisciplinary Team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) note dated 3/11/24 indicated that on 3/8/24, at approximately 11:10 a.m., a Certified Nursing Assistant (CNA) alerted the licensed nurse that residents had a disagreement. The licensed nurse went to the room, and when she entered the room, the licensed nurse saw Resident 2 standing on the right side of Resident 1's bed. Resident 1 claimed that Resident 2 hit him in the head twice. The licensed nurse noted a skin tear on the side of the right eye with a small amount of blood on Resident 1. Review of Resident 1's physician's order dated 3/8/24 indicated "cleanses the skin tear to the right lateral periorbital area with NS (normal saline), pat dry, then apply steri-strips for 1 day; monitor right lateral periorbital area skin tear for s/sx (signs/symptoms) of infection for 14 days." During an observation and interview on 4/4/24 at 11:30 a.m., Resident 1 was observed lying in bed, awake and alert, with some confusion. Resident 1 stated that he did not have any trouble with co-residents and could not remember someone hitting him. Review of Resident 2's clinical record indicated he was admitted to the facility on 1/18/24 with diagnoses including mild cognitive impairment (problems with a person's ability to think, learn, and remember), depression (a mood disorder that causes a feeling of sadness and loss of interest), and alcohol dependence (a chronic disease characterized by uncontrolled drinking alcohol). Resident 2's MDS, dated 1/24/24, indicated a BIMS score of 14 (intact cognition). Review of Resident 2's care plans indicated a plan to address an allegation of abuse, perpetrator. The interventions included monitoring for episodes of hitting others and initiating room changes. Review of Resident 2's IDT note dated 3/8/24 indicated that on 3/8/24, at approximately 11:10 a.m., the licensed nurse saw Resident 2 standing on the right side of Resident 1's bed. Resident 2 reported that he was annoyed by Resident 1, Resident 1 told him that he was ugly, and then he got mad and slapped Resident 1 twice. Resident 2 was aware of what he did to his roommate. During an observation and interview on 4/4/24 at 11:50 a.m., Resident 2 was sitting up in his wheelchair in the big dining room, alert and calm. Resident 2 stated that he remembered having trouble with his ex-roommate but could not recall if he hit his ex-roommate. Review of the facility's 5 day follow up investigative summary dated 3/13/24 indicated that on 3/8/24 at 11:10 a.m., a licensed nurse (LN) responded to the residents' room after receiving the report from a CNA that the residents were having a disagreement. When the LN came into the room, she saw Resident 2 standing on the side of the bed of Resident 1 who was lying on his bed. The licensed nurse did not witness the actual incident of the altercation. Resident 1 stated that he was hit on the right side of his face/eye by Resident 2 twice. Resident 2 admitted to hitting Resident 1, saying that he got annoyed by Resident 1 as Resident 1 was yelling at nursing staff. The summary further indicated, "Conclusion: physical altercation between two male residents was verified based upon staff and resident interviews and injury sustained by the victim." During a telephone interview on 5/3/24 at 12:55 p.m. with Licensed Vocational Nurse A (LVN A), he stated that he heard loud voices from the hallway and went to the residents' room. He saw Resident 2 standing at the side of Resident 1's bed. Resident 1 claimed he got hit on the face twice by Resident 2. Resident 1 was observed with a skin tear above his eyebrow. Resident 2 stated he hit Resident 1 twice because he was annoyed by Resident 1. During an interview on 5/2/24 at 3:58 p.m. with the Administrator (ADM), the ADM stated the facility considered the incident an altercation, not abuse, because Resident 2's act was not intentional to harm Resident 1. During a review of the facility's Policy and Procedure (P&P) titled "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," revised 4/2021, the P&P indicated, "Residents have the right to be free from abuse ... 1. Protect residents from abuse ... by anyone including, b. other residents ..." During a review of the facility's Policy and Procedure (P&P) titled "Abuse Prohibition Policy and Procedure," effective date 2/23/21, the P&P indicated, "Healthcare centers prohibits abuse ...Abuse is defined as the willful infliction of injury ...Physical Abuse includes hitting, slapping ..." The facility failed to ensure residents were from physical abuse when Resident 2 hit Resident 1 in the face, causing injury to Resident 1's above the eyebrow area and first aid being administered. Resident 2's act of hitting Resident 1 in the face was deliberate act to inflict harm or injury, not accidental; therefore, his action was deemed a willful act and considered abuse. This failure had the potential to cause both physical and emotional harm to all residents. This failure had direct relationship or immediate relationship to the health, safety, and security of the resident.