Health inspection·June 17, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported Incident # CA00874766 and Complaint # CA00875588 Event ID: 12V511 Representing the Department, HFEN # 3150 State Citation A was written F600, §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; Title 22 CCR §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. Title 22 CCR §72527. Patients' Rights. (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 12/15/23, an unannounced visit was conducted at the skilled nursing facility to investigate a Facility Reported Incident and a complaint regarding Resident Abuse. Resident 1 was not free from physical abuse when Resident 1 was found in bed with multiple bruises to the face and arms, swelling on the bridge of the nose and right eyebrow, a cut on the lower lip, blood in the mouth, on the lips, and on the fingers, and chipped teeth. Resident 1 passed away, and the immediate cause of death was documented as, "Blunt force injury [injury caused by forceful impact from an object without sharp edges or points] of head complicating hypertensive [having high blood pressure] and atherosclerotic cardiovascular disease [heart disease involving plaque buildup in the arteries]." Review of Resident 1's medical record indicated Resident 1 was admitted to the facility on 4/13/23, and had diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually caused by infection), chronic obstructive pulmonary disease (COPD, a disease that causes obstructed airflow from the lungs), severe protein-calorie malnutrition (significant fat loss and muscle wasting), muscle weakness, paroxysmal atrial fibrillation (a type of irregular heart rate), stage 4 pressure ulcer (an injury resulting from prolonged pressure that involves full thickness tissue loss with exposed bone, tendon or muscle), congestive heart failure (a condition in which the heart cannot pump blood well enough to provide a normal supply to the body), osteoporosis (a condition that causes the bones to become brittle and fragile), and osteoarthritis (degeneration of the joints that causes pain and stiffness). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/28/23, indicated Resident 1 had a brief interview for mental status (BIMS) score of 3 (a score of 0 to 7 indicates severe cognitive impairment [problems with how a person thinks, learn, use judgment and make decisions]). The MDS indicated Resident 1 required substantial/maximal assistance (staff does more than half the effort) for rolling left and right in bed. The MDS also indicated Resident 1 was dependent (staff does all of the effort) for moving from a lying to sitting position in bed and moving from a sitting to lying position in bed. The MDS further indicated Resident 1 refused to move from a sitting to standing position and refused to transfer to and from her bed to a chair or wheelchair. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a tool used to communicate information to the resident's doctor), dated 12/13/23, indicated Resident 1 was involved in an incident of alleged physical abuse. The SBAR indicated, "Found bruises on the resident's nose bridge, left and right cheek, left forehead, and chin. Also noted that the resident's front upper teeth were chipped and there is dried blood on the lower lip. There is also swelling on the bridge of the nose." The SBAR also indicated Resident 1 had, "extensive bruising on face and arms. Blood in mouth and on lips and fingers." The SBAR also indicated Resident 1 "has bruising on the right side of the face, bruising on the lips, swelling on the right eyebrow area." The SBAR further indicated, "The resident has a multiple discoloration and swelling on her face, chipped upper front teeth and cut on the lower lip." During an interview with certified nursing assistant (CNA) A on 12/15/23, at 2:13 p.m., CNA A stated when she started work at 3:00 p.m. on 12/13/23, Resident 1 was in bed sleeping. CNA A stated she later provided care to Resident 1 at 6:30 p.m., at which time the resident did not have any injuries. CNA A stated the next time she saw Resident 1, at around 8:30 p.m. or 9:30 p.m., she saw bruises on Resident 1's face and blood on Resident 1's lips. CNA A stated she did not know of anyone who saw what happened to Resident 1. She stated Resident 1 was not able to get out of bed, and Resident 1 did not have any behaviors of self-harm. During an interview with registered nurse (RN) B on 12/15/23, at 3:17 p.m., RN B stated on 12/13/23, she and RN C were informed by RN D that Resident 1 had injuries to her face. RN B stated when staff asked Resident 1 what happened, the resident stated she did not know. RN B stated Resident 1 did not have behaviors of self-harm, and it was unlikely that Resident 1 inflicted the injuries on herself. RN B stated staff had determined Resident 1 did not fall out of bed, as the resident was dependent with care and would not have been able to get up and get herself back into bed after a fall. During an interview with RN C on 12/15/23, at 3:32 p.m., RN C stated on 12/13/23, at around 9:45 p.m., she was notified of Resident 1's injuries. RN C stated she went to the resident's room and saw Resident 1 in bed with bruises and swelling on her face, chipped teeth, and a cut on the inside of her lower lip. RN C stated Resident 1 did not remember what happened. RN C stated it was not likely that Resident 1 fell and got herself back into bed. During an interview with RN D on 12/15/23, at 3:49 p.m., RN D stated on 12/13/23, she initially saw Resident 1 at around 3:00 p.m. or 4:00 p.m., and Resident 1 did not have injuries at that time. RN D stated she gave medications to Resident 1 between 5:30 p.m. and 6:00 p.m. and the resident still had no injuries. RN D stated CNA A informed her of Resident 1's injuries at around 9:30 p.m. RN D stated she went into Resident 1's room and saw bruising and swelling on Resident 1's face, a chipped tooth, and a cut with dried blood on her lip. RN D stated she did not think Resident 1 would have been able to get herself back into bed if she fell. She also stated she did not think Resident 1 caused the injuries herself, as Resident 1 did not have behaviors of hitting or harming herself. Review of the facility's undated investigation summary indicated that on 12/13/23, CNA A went into Resident 1's room and noted Resident 1 had, "multiple bruises and swelling on her face, chipped front teeth and cut on lower lip." The investigation summary further indicated Resident 1 was sent to the acute hospital for further evaluation. Review of Resident 1's Emergency Department Attending Physician Note, dated 12/14/23, indicated Resident 1 was brought in by ambulance after Resident 1 "was assaulted at her nursing facility." The note indicated, "Yesterday evening patient was assaulted between the hours of 9 and 11." The note further indicated, "Patient is more altered than normal today. She has not been talking at all today and usually she can have a conversation. She has bruising to the right side of her face and a chipped tooth." Review of Resident 1's Medicine History and Physical from the acute hospital, dated 12/14/23, indicated, "Noted abrasions on left side of face, bruising around the lips with chipped tooth." The Medicine History and Physical indicated diagnostic imaging showed Resident 1 had, "Mild right malar soft tissue swelling [mild swelling in the right facial cheek area]." Review of Resident 1's Physician Discharge Summary from the acute hospital, dated 12/15/23, indicated Resident 1 was declared deceased (dead) at 4:06 p.m. The Physician Discharge Summary further indicated Resident 1's family requested an autopsy (examination to determine the cause of death) and the coroner (an official who investigates violent, sudden, or suspicious deaths) was notified. Resident 1's Certificate of Death, issued 4/15/24, was reviewed. The first page of the certificate indicated Resident 1's immediate cause of death was "Pending." The second page of the certificate contained a Physician/Coroner's Amendment that indicated Resident 1's immediate cause of death was, "Blunt force injury of head complicating hypertensive and atherosclerotic cardiovascular disease." The Physician/Coroner's Amendment indicated Resident 1's injury occurred on 12/13/23 at [facility address] and indicated, "Bedbound subject found in bed with facial trauma in a shared room at a skilled nursing facility." The Physician/Coroner's Amendment further indicated Resident 1's manner of death was, "Homicide [the killing of one person by another]." The facility's policy titled "Alleged or Suspected Abuse and Crime Reporting," revised 10/2022, indicated each resident has the right to be free from abuse. Resident 1 was not free from physical abuse when Resident 1 was found in bed with multiple bruises to the face and arms, swelling on the bridge of the nose and right eyebrow, a cut on the lower lip, blood in the mouth, on the lips, and on the fingers, and chipped teeth. Resident 1 passed away, and the immediate cause of death was documented as, "Blunt force injury of head complicating hypertensive and atherosclerotic cardiovascular disease." The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.