Other·April 22, 2024

Grant Cuesta Sub-Acute and Rehabilitation Center Exit Date: 3/21/2024 Intake #: CA00870437, CA00870680, CA881961, CA00885373, CA00885687 Event ID: 7S4P11 F607 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. §483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. §483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act. On 2/26/24 at 1:45 p.m., an unannounced visit was conducted at the facility to investigate Entity Reported Incidents regarding Resident/Patient/Client Abuse. The facility failed to follow their abuse policy when: 1. Resident 1 had altercations with three residents (Residents 2, 3, and 4) over a four-month period. After Resident 1 and Resident 2 had an altercation on 11/16/23, the residents' care plans were not revised and there were no documented interventions to prevent future occurrences. After Resident 1 and Resident 4 had a verbal altercation on 2/15/24, the residents' care plans were not revised and there were no documented interventions to prevent recurrence between the two residents. On 2/17/24, Resident 1 and Resident 4 had a physical altercation, which caused injury to Resident 4's leg. 2. After Resident 5 allegedly hit Resident 6's hand, Resident 5's care plan was not revised and there was no documentation that indicated the interventions implemented to prevent possible future altercations. These failures had the potential to put other residents' safety at risk and resulted in repeated altercations involving Resident 1 and resulted in an abrasion on Resident 4's lower leg. 1. On 11/20/23 at 8:56 a.m., California Department of Public Health (CDPH) received a faxed report containing form SOC 341, "Report of Suspected Dependent Adult/Elder Abuse." The report indicated on 11/16/23, "Facility staff reported the witnessed verbal and possible physical altercation between [Resident 2] and [Resident 1]." Review of Resident 1's medical record indicated he was admitted to the facility with diagnoses including hemiplegia and hemiparesis (complete paralysis, partial paralysis or muscle weakness on one side of the body) following cerebral infarction (stroke, damage to the brain due to lack of oxygen) affecting right dominant side. Review of Resident 2's medical record indicated he was admitted to the facility with diagnoses including encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (deepest layer of tissue in the skin). Review of Resident 1's care plan indicated there was no care plan that addressed Resident 1's altercation with Resident 2. There was no documentation that indicated Resident 1 was supervised to prevent future incidents and protect other residents. There was no documentation in the care plan that indicated the interventions implemented to prevent Resident 1's possible future altercations. Review of Resident 2's care plan indicated there was no care plan that addressed Resident 2's altercation with Resident 1. There were no documented interventions that addressed Resident 2's psychosocial needs after the altercation with Resident 1. On 1/16/24 at 9:23 a.m., CDPH received a faxed report containing form SOC 341, "Report of Suspected Dependent Adult/Elder Abuse." The report indicated on 1/13/24, "[Resident 3] alleged that his roommate [Resident 1] jumped on top of [Resident 3] who was in bed, and hit [Resident 3] in the face, chest with his fist." Review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendation) - Alleged Abuse Report of Incident, dated 1/13/24 indicated, "Upon arrival into the room, [Resident 1] was on top of his roommate holding his neck [with] his left hand and punching continuously with his opposite arm. Immediately separated the scuffle." On 2/16/24 at 4:10 p.m., CDPH received a faxed report containing form SOC 341, "Report of Suspected Dependent Adult/Elder Abuse." The report indicated on 2/15/24, "Facility staff responded to the verbal altercation in resident room, observed residents [Resident 1 and 4] were engaging in a heated conversation with raised voices." Review of Resident 4's medical record indicated he was admitted to the facility with diagnoses including Type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar) and peripheral vascular disease (a blood vessel disorder that affects blood circulation). Review of Resident 4's minimum data set (MDS, an assessment tool), dated 2/29/24 indicated his Brief Interview for Mental Status (test for cognition level) was 15, meaning the resident was cognitively intact. Review of Resident 4's social services notes, dated 2/16/24 indicated, "Checked up on [Resident 4] after altercation with roommate and [Resident 4] is doing well and is fine sharing rooms with roommate still." Review of Resident 1's care plan indicated there was no care plan that addressed Resident 1's altercation with Resident 4. There was no documentation that indicated Resident 1 was supervised to prevent future incidents and protect other residents. There was no documentation in the care plan that indicated the interventions implemented to prevent Resident 1's possible future altercations. Review of Resident 4's care plan indicated there was no care plan that addressed Resident 4's altercation with Resident 1. Review of Resident 4's SBAR-Physical Injury Report of Incident, dated 2/17/24 indicated, "[Resident 4] was the receiver of a res to res [resident to resident] physical altercation. The two residents were separated by staff. [Resident 4] noted with abrasion to right lower leg after the BS [bedside] table was pushed into his leg. Review of Resident 4's care plan indicated there was no care plan that addressed Resident 4's second altercation with Resident 1. There were no documented interventions in the care plan that addressed Resident 4's psychosocial needs after the second altercation with Resident 1. During an interview on 2/26/24 at 1:40 p.m., the administrator (ADM) stated the facility tried to move Resident 1 and Resident 4 apart after the 2/15/24 altercation. The ADM stated the facility kept Resident 1 and Resident 4 in same room and on 2/17/24, they got into another altercation. During an interview on 2/26/24 at 2 p.m., Resident 4 stated Resident 1 came into the room and started an argument. He stated Resident 1 pushed the bedside table and the table hit his leg. During an interview on 3/21/24 at 2:41 p.m., the ADM stated nurses definitely should have done a care plan for Resident 1. He stated nurses were on high alert, but there is no documentation to prove nurses were monitoring Resident 1. During a telephone interview on 3/25/24 at 3:29 p.m. with the director of nursing (DON) and ADM, the DON stated the facility will provide missing documentation as soon as possible. On 3/26/24, documentation was provided to CDPH. The documentation included Resident 1's "Timeline" which indicated social services notes and medication changes for Resident 1 on 1/25/24 and 2/22/24. The documentation also included Resident 1's Medication Administration Record for March 2024, which indicated nurses monitored Resident 1 for episodes of striking out, cursing at staff, irritability, and angry outbursts. There was no documentation that indicated nurses monitored Resident 1 of these behaviors prior to 3/8/24. There was no documentation that indicated Resident 1's care plan was revised with interventions implemented to prevent future altercations with residents. There was no documentation that indicated an intervention was implemented to prevent Resident 1 and Resident 4 from having another altercation. 2. On 1/26/24 at 3:50 p.m., CDPH received a faxed report containing form SOC 341, "Report of Suspected Dependent Adult/Elder Abuse." The report indicated on 1/25/24 "[Resident 6] reported that her roommate [Resident 5] hit the back of her hand resting on the overbed table." Review of Resident 5's medical record indicated she was admitted to the facility with diagnoses including dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning) and bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making). Review of Resident 5's social services notes, dated 1/26/24 indicated, "[Resident 6] hit her roommate because [Resident 6] wanted roommate to turn her light off." Review of Resident 6's medical record indicated she was admitted to the facility with diagnoses including multiple fractures of ribs and asthma (inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath). Review of Resident 6's SBAR - Alleged Abuse Report of Incident, dated 1/25/24 indicated Resident 6 complained that her roommate, Resident 5, slapped her on her hand. Review of Resident 5's care plan indicated there was no care plan that addressed Resident 5's alleged physical altercation with Resident 6. There was no documentation that indicated Resident 5 was supervised to prevent future incidents and protect other residents. There was no documentation in the care plan that indicated the interventions implemented to prevent Resident 5's possible future altercations. During an interview on 3/21/24 at 10:35 a.m., the ADM confirmed Resident 5 did not have a care plan regarding her altercation with Resident 6. The ADM stated the interdisciplinary team discussed all incidents during their daily "stand-up" meetings, but did not document what was discussed. During an interview on 3/21/24 at 10:40 a.m., the DON stated an SBAR was supposed to be done in both residents' charts. She stated the process for resident to resident altercations was not very clear to staff prior to January 2024 when she started working in the facility. The DON stated the issue was identified and the facility needs to better their process and educate staff. Review of the facility's policy, "Alleged or Suspected Abuse and Crime Reporting," revised 10/2022 indicated, "The facility will monitor the adequacy of assessment, care planning and monitoring of residents with needs or behaviors that may likely lead to conflict, altercation, abuse, neglect, exploitation and misappropriation and mistreatment such as: Physical aggressive or self-injurious behaviors; Verbally abusive behavior towards others; socially inappropriate or disruptive behaviors; wandering into the rooms or person space of others; Those requiring heavy nursing care and/or are fully dependent on staff." The policy indicated, "To protect residents and employees from harm or retaliation during an investigation, the facility shall: Take reasonable measures to separate residents involved in abuse or altercations; Examine alleged victim for signs of physical injury or psychosocial assessment if needed; Increased supervision of the alleged victim and residents as indicated; ... Provide emotional support and counseling to the resident during and after investigation, as needed; Revise resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse." The policy also indicated, "The facility will take necessary actions that are appropriate based on the nature of allegation and results of investigation, which may include, but are not limited to, the following: a. Analyzing occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences." In violation of the above cited standards, the facility failed to follow their abuse policy when: 1. Resident 1 had altercations with three residents (Residents 2, 3, and 4) over a four-month period. After Resident 1 and Resident 2 had an altercation on 11/16/23, the residents' care plans were not revised and there were no documented interventions to prevent future occurrences. After Resident 1 and Resident 4 had a verbal altercation on 2/15/24, the residents' care plans were not revised and there were no documented interventions to prevent recurrence between the two residents. On 2/17/24, Resident 1 and Resident 4 had a physical altercation, which caused injury to Resident 4's leg. 2. After Resident 5 allegedly hit Resident 6's hand, Resident 5's care plan was not revised and there was no documentation that indicated the interventions implemented to prevent possible future altercations. These failures had the potential to put other residents' safety at risk and resulted in repeated altercations involving Resident 1 and resulted in an abrasion on Resident 4's lower leg. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.