Health inspection·November 15, 2024

California Code of Regulations, Title 22, section 72315 (b) Nursing Service- Patient Care. (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. California Code of Regulations, Title 22, section 72523 (a) 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. California Code of Regulations, Title 22, section 72527 (a) (10) 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. Code of Federal Regulations, Title 42, 483.12 (a) (1) 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. The facility must- Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone. It was determined that the facility failed to ensure patients (Patient 1 and 2) involved in multiple altercations (physical fight) were separated and distanced away from each other in accordance with the care plan. This failure resulted in Patient 1 to be grabbed and to be pulled out from the wheelchair which led to a closed clavicle fracture (broken collarbone). On October 2, 2024, at 8:30 a.m., an unannounced visit to the facility was conducted to investigate an allegation of physical abuse. On October 2, 2024, Patient 1's admission record was reviewed. Patient 1 was admitted to facility on February 9, 2024, with diagnoses which included bipolar disorder (a mental illness that causes extreme mood swings). A review of Patient 1's "History and Physical," dated February 9, 2024, indicated Patient 1 can make needs known but cannot make medical decisions. A review of Patient 1's "Minimum Data set (an assessment tool)," dated August 12, 2024, indicated Patient 1 had a Brief Interview for Mental Status (tool used to assess a resident's cognitive function) score of 10 (moderate cognitive impairment). A review of Patient 1's "COC (Change of Condition)/Interact Assessment Form," indicated the following: - September 13, 2024, at 6:34 p.m., "...At 1834 (6:34 p.m.) in the hallway, outside room 49 (not Patient 1 or Patient 2's room; another patient's room) ...Staff heard a commotion between two residents...Resident (Patient 1) was pushed by another resident (Patient 2) on his right side of his head... (First Incident)" - September 14, 2024, at 10:45 a.m., "...At 10:45 outside room 49 (not Patient 1 or Patient 2's room; another patient's room). ...Staff heard a commotion between two residents...Resident (Patient 1) was hit by another resident (Patient 2) on his right side of his head... (Second Incident)" A review of Patient 1's "Care Plan," dated September 13, 2024, indicated, "...Focus: Resident is at risk for emotional/psychosocial distress related to being victim of a resident-to-resident altercation on 9/13/2024 and 9/14/2024...Interventions: Keep the 2 involved resident apart from each other...Redirect resident when needed..." A review of Patient 1's "Progress Notes," indicated the following: - September 30, 2024, at 10 a.m., "...Staff reported that resident was on the floor after being pulled out of his chair at approximately 1000 am...Upon assessment resident complained of pain to the left side of his head and left shoulder...Sent to (name of general acute care hospital [GACH]) for further evaluation...(Third Altercation)" - September 30, 2024, at 5:12 p.m., "...Received resident from (name of company) transportation @ (at) 1603 hours (4:03 p.m.)...Resident has new diagnosis of closed fracture of left clavicle...Uses sling to support left arm..." A review of Patient 1's "General Emergency Department Discharge Instructions," dated September 30, 2024, indicated the following: - Diagnosis: Closed fracture of left clavicle...Victim of assault. - XR (X-Ray) Shoulder 2 or More Views-Left...Findings: Minimally displaced distal clavicular fracture with regional soft tissue swelling. On October 2, 2024, Patient 2's admission record was reviewed. Patient 2 was admitted to facility on July 11, 2024, with diagnoses which included schizophrenia (a severe mental disorder affecting a person's emotions and perception of reality). A review of Patient 2's "History and Physical," dated September 20, 2024, indicated Patient 2 does not have the capacity to understand and make decisions. A review of Patient 2's "COC/Interact Assessment Form," indicated the following: - September 13, 2024, at 6:34 p.m., "...At 1834 (6:34 p.m.) outside room 49 (not Patient 1 or Patient 2's room; another patient's room)...Staff heard a commotion between two residents...Resident (Patient 2) pushed another resident (Patient 1) on his right side of his head...(First Incident)" - September 14, 2024, at 2 p.m., "...Resident on 1:1 (one on one) monitoring for aggressive behavior...Around 10:45 a.m....One resident (Patient 1) passed by his room and resident (Patient 2) suddenly attacked and hit the other resident...(Second Incident)" A review of Patient 2's "Care Plan," dated September 13 to 14, 2024, indicated, "...Focus: Resident to resident interaction on 9/13/2024 and 9/14/2024...Resident is the aggressor...Interventions: Keep the 2 involved residents apart from each other...Provide redirection when needed..." A review of Patient 2's "Progress Notes," dated September 30, 2024, at 11:01 a.m., indicated, "...Resident was observed pulling another resident out of their chair at approximately 10 am unprovoked...Incident observed by staff and staff unable to redirect resident prior to him pulling the other resident out of his chair...(Third Altercation)" On October 2, 2024, at 11:25 a.m., during an interview with the Infection Preventionist (IP), she stated on September 30, 2024, around 10 a.m., she was with Patient 2 at the front lobby reception window and saw Patient 1 on his wheelchair coming in the lobby front door. The IP stated she asked the DM (Dietary Manager) to bring Patient 1 to the activity room to divert away from Patient 2 due to two previous altercations involving the two patients (Patients 1 and 2). The IP stated while the DM wheeled Patient 1 down the lobby hallway, Patient 1 yelled "(vulgar word)" to Patient 2. The IP further stated Patient 2 charged towards Patient 1, grabbed his shirt, pulled Patient 1 off his wheelchair, and dropped him on the floor which caused Patient 1 to fall on his left side. The IP stated Patient 1 was sent to the hospital and the patient came back with diagnosis of left clavicle fracture. The IP stated the DM should have redirected Patient 1 out of the lobby to the alternate entrance at the side of the facility and she should have redirected Patient 2 away from the lobby to prevent interaction between the patients. On October 2, 2024, at 12:02 p.m., during an interview with the DM, the DM stated she was aware Patient 1 and Patient 2 had previous altercation incidents with each other and needed to be apart and redirected away from each other at all times. The DM stated on September 30, 2024, around 10 a.m., the IP asked her to bring Patient 1 into the activity room while the IP was with Patient 2 at the front lobby reception window. The DM stated she wheeled Patient 1 down the lobby hallway towards Patient 2 and the IP, when Patient 1 turned his head and yelled "(vulgar word)" to Patient 2. The DM further stated Patient 2 ran towards Patient 1, grabbed, and pulled his shirt which caused Patient 1 to fall on the floor to his left side. The DM stated she should have redirected Patient 1 into the entrance at the side of the facility away from Patient 2 to prevent interaction between the patients which could have avoided the altercation incident. On October 2, 2024, at 1:44 p.m., during an interview and review of Patient 1 and Patient 2's progress notes and care plans with the Director of Nursing (DON), she stated Patient 1 and Patient 2 had two previous altercations on September 13 and 14, 2024. The DON stated all facility staff were aware to keep both patients apart from each other at all times. The DON stated Patient 1 and Patient 2 had a third altercation incident on September 30, 2024, around 10 a.m. in the front lobby where Patient 2 charged at Patient 1 and pulled and flipped him (Patient 1) off his wheelchair, which caused the patient (Patient 1) to fall on the floor to his left side. The DON further stated Patient 1 was sent to the hospital and the patient came back to the facility with diagnosis of left clavicle fracture as a result of the incident on September 30, 2024. The DON stated the DM and the IP should have redirected Patient 1 and Patient 2 in the opposite direction of each other to avoid further contact which could have prevented the altercation incident. A review of the facility policy and procedure titled, "Abuse & Mistreatment of Residents," undated, indicated, "...Purpose: To uphold a resident's right to be free from...abuse...Facility shall make reasonable efforts to protect residents from harm...If the suspected perpetrator is another resident, residents shall be separated to avoid any further contact..." It was determined that the facility failed to ensure patients (Patients 1 and 2) involved in multiple altercations were separated and distanced away from each other in accordance with the care plan. This failure resulted in Patient 1 to be grabbed and to be pulled out from the wheelchair which led to a closed clavicle fracture. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.