Health inspection·January 16, 2025

Complaint number: CA00930842 California Code of Regulations, Title 22, section 72311, Nursing Service- General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulation, Title 22 section 72523 Patient Care Policies and Procedure 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Code of Federal Regulations, Title 42, 483.25(d)(1)(2) (d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. It was determined that the facility failed to provide effective supervision for Patient 2, who had history of exhibiting unprovoked aggressive behavior towards staff members and had history of altercation with other patients in the facility. This failure resulted in Patient 2 hitting Patient 1 on the left side of the face with a plastic plate cover. Patient 1 sustained a black bruise and swelling above the corner of the left upper lip. On November 19, 2024, at 11:13 am., an unannounced visit to the facility was conducted to investigate a complaint and facility Reported Incident on an allegation of abuse. On November 19, 2024, at 1:29 p.m., Patient 2 was observed sitting in the hallway adjacent to the nurse's station, sitting in his wheelchair. In a concurrent interview with Patient 2, he stated that he hit a lady (Patient 1) with a plate cover because the patient stabbed him with a pen. However, Patient 2 was unable to recall the date of the incident nor the name of the patient he allegedly hit. On November 19, 2024, at 2:02 p.m., Patient 1 was observed in the Activity Room, sitting in a wheelchair at a table sipping on coffee. Patient 1 had a purple to black bruise above the corner of her left upper lip. A review of Patient 2's "Admission Record," indicated, Patient 2 was admitted to the facility on August 25, 2024, with diagnoses which included dementia (memory loss) and schizoaffective disorder (a mental health condition with symptoms of delusions [believing things that are not real], hallucinations [seeing things or hearing voices] and mood disorder [affects the emotional state]). A review of Patient 2's "History and Physical," dated August 28, 2024, indicated he had fluctuating capacity to make decisions. A review of Patient 2's "Progress Notes," dated October 12, 2024, at 1:40 p.m., indicated, "At around 12:15 p.m., this patient barged into (room of another patient, not Patient 1) and started arguing with a Certified Nursing Assistant (CNA)... Resident argues that (room number of another patient, not Patient 1) is his room and that he needs to be assisted back to his bed immediately. CNA redirected resident (sic) by stating that he has been moved to another room and that he will be assisted right away after she is done feeding (room number of another patient, not Patient 1). This agitated the resident instantly. Resident then started to scream profanity; grabbed a stainless steel (sic) fork from his pants and physically assaulted the CNA towards the left side of her abdomen. CNA sustained fork- related superficial abrasions to said area... Resident then wheeled himself towards the activity area and started making verbal threats to other facility staff who are trying to stop him from grabbing more forks from the dining tables. Incident happened past noon time where other residents are still eating. Close supervision provided to ensure everyone's safety." A record review of Patient 2's care plan dated October 21, 2024, indicated, "Focus... Psychosocial- Behavior: Exhibits or is at risk for behavioral symptoms (i.e., striking out, grabbing others, combative, verbally, or physically abusive) due to: Schizoaffective disorder, impulse disorder >Another Resident claims he hit her on the left side of her face and head...Interventions... Observe whether the behavior endangers the resident and/or others. (Intervene if necessary: removing others from the surrounding area) ..." A review of Patient 2's progress notes titled "Nurse Practitioner Note, "dated October 24, 2024, indicated,"... (Patient 2) was involved in an incident with a female peer (Patient 3) ... the patient (Patient 2) entered a female peer's room, causing her to yell and scream...The female peer initially accused the patient of hitting her but later recanted upon police arrival. However, she (Patient 3) maintained that the patient (Patient 2) had grabbed her and made threats...Assessment and Plan Aggressive Behavior and Safety Concerns...Patient's impulsive and aggressive behavior poses a risk to himself and others in the facility...Plan...Implement increased supervision and safety measures...Consider 1:1 observation if aggressive behaviors escalate...Follow-up and monitoring...instruct staff to maintain detailed logs and report any significant changes or incidents immediately...the overall goal is to stabilize the patient's mental state, reduce aggressive behaviors, and ensure the safety of both the patient and others in the facility. Close monitoring and frequent reassessment will be crucial in managing this complex case..." A review of Patient 2's progress notes titled, "Behavior Note, "dated October 28, 2024, indicated, "...At 6:30 pm CNA (name) called me (RN [Registered Nurse] Supervisor) ...I immediately went to the room and found the resident (Patient 2) inside the bathroom...which is not his room. Resident was agitated, combative, and always cursing/yelling disturbing other residents inside the room...the resident insistently stayed inside the bathroom...The resident was holding a shaving cream bottle, he removed the cap, threw it at the CNA and when the CNA tried to get the cap he punched the CNA in the face...Resident won't listen to the any staff and he continued yelling inside...Reported to MD (medical doctor) with no new order...Assigned another CNA and will do buddy system when providing care to the resident..." A review of Patient 2's progress notes titled, "Nurses Notes," indicated the following: - November 2, 2024, "...At about 8 PM, resident became aggressive, yelling and trying to open the exit door in hallway 2. Charge Nurse (CN) and other staffs redirected him unsuccessful, due to resident swung his arms to hit staffs. Resident stood up, exit door opened, the alarm sounded, resident startled and dropped him down back to w/c, at that time the door closed and somehow caused an abrasion (scrape against a rough surface) on his left knee and s/t (skin tear) on his left forearm..." - November 3, 2024, "...Approx. (approximately) 8:30 am I was made aware that the resident stuck her in the wrist with the call light while trying to provide patient care. I attempted to communicate with the resident, and he continued to tell me 'they are trying to kill me, and I will slice their throats' I continued to keep my distance and trying to calm the resident down, he continues to yell and make aggressive statements such as 'If they come towards me, I will kill them all'..." A review of Patient 2's "Progress Notes," dated November 16, 2024, at 5 p.m., indicated, "At about 3 pm, CN heard loud noise in dining room, CN went there, saw Activity staff trying to separate [Patient 1] from [Patient 2], [Patient 1] was crying at this time. Activity staff said [Patient 2] used the cover of plate to hit [Patient 1]'s left side of face. CN saw a little bruise on her left upper mouth. CN asked her if she was in pain, she said yes..." A review of Patient 1's admission record indicated she was admitted on January 18, 2024, with diagnoses of type 2 diabetes mellitus, (a chronic condition that affects the way the body uses sugar), dementia, (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Patient 1's "History and Physical," dated January 24, 2024, indicated she did not have the capacity to make decisions. A record review of Patient 1's "Progress Notes," dated November 16, 2024, at 5 p.m., indicated, "At about 3 pm, CN heard loud noise in dining room, CN went there, saw activity staff trying to separate [Patient 1] from [Patient 2] (sic) [Patient 1] was crying at this time. Activity staff said [Patient 2] used the cover of plate to hit [Patient 1's] left side of face. CN saw a little bruise on her left upper mouth. CN asked her if she was in pain, she said yes... " A review of Patient 1's "Wound Evaluation," dated November 17, 2024, at 7:53 a.m., indicated, "...Bruise Body Location: - Upper - Left - Lip New - 1 day old... Dimensions Area 3.22 cm Length 2.8 cm Width 1.71 cm..." On November 19, 2024, at 2:12 p.m., an interview was conducted with CNA 1. CNA 1 stated she was familiar with Patient 2. CNA 1 stated Patient 2's behavior had been getting worse. CNA 1 stated that she had been stabbed in the abdomen with a fork by Patient 2 and she stated that Patient 2's behavior was unpredictable and had gotten worse. CNA 1 stated Patient 2 required close supervision by CNA and Activity staff. She stated someone should be supervising the patient (Patient 2) and keeping him away from other patients. On November 19, 2024, at 2:47 p.m., an interview was conducted with a Licensed Vocational Nurse (LVN). The LVN stated she was assigned to Patient 2, and she stated Patient 2 had been more aggressive and the patient needed constant supervision. The LVN stated Patient 2 was a danger to other patients during his episodes of aggressive behavior, and that a one on one (1:1) supervision would require one staff member to be supervising one patient. The LVN stated Patient 2 was not on 1:1 supervision. On November 19, 2024, at 3:11 p.m., during interview, the RN stated when Patient 2 had aggressive behavior, the patient was a danger to other patients. The RN stated Patient 2 was previously accused of hitting a female patient (patient different from Patient 1). The RN stated the patient (Patient 2) should have been on close supervision. On November 19, 2024, at 4:49 p.m., an interview was conducted with CNA 3. CNA 3 stated, she was assigned to Patient 2 on November 16, 2024, and she was to supervise the patient due to the patient's violent behavior. CNA 3 stated on November 16, 2024; she left Patient 2 in the dining room to provide care to another patient. CNA 3 stated Patient 2 was sitting in his wheelchair one table away from Patient 1. CNA 3 stated she returned to the activity room when she heard Patient 2 in his wheelchair, yelling, and holding a plastic cover, near a crying Patient 1. CNA 3 stated she did not feel safe caring for Patient 2, as his behavior had been becoming increasingly violent. On November 19, 2024, at 5:47 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated on November 16, 2024, the Activity Assistant (AA) was not within arm's length of Patient 2 and was unable to prevent the patient from hitting Patient 1 with the plate cover. On November 27, 2024, at 12:38 p.m., a telephone interview was conducted with the AA. The AA stated on November 16, 2024, at approximately 3 p.m., he was in the dining room. However, he stated he left the dining area to return empty dinner trays, and as he came back to the dining area, he witnessed Patient 2 wheel himself over to Patient 1 and hit her in the face with a plastic plate cover. The AA stated he was not close enough to physically intervene, so he shouted at Patient 2 to stop. On December 9, 2024, at 3:46 p.m., a telephone interview was conducted with the DON. The DON stated that if the patient could not be re-directed, the staff should have notified the physician. The DON stated that supervision for Patient 2 should be for a staff to be close enough to intervene. A review of the facility policy and procedure titled, "Behavioral Assessment, Intervention and Monitoring," revised March 2019, indicated, "...The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and other from harm...Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress...Interventions and approached will be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes..." Based on observations, interviews, and record review, the facility failed to provide effective supervision for Patient 2, who had history of exhibiting unprovoked aggressive behavior towards staff members and had history of altercation with other patients in the facility. This failure resulted in Patient 2 hitting Patient 1 on the left side of the face with a plastic plate cover. Patient 1 sustained a black bruise and swelling above the corner of the left upper lip. These 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.