Other·February 1, 2024

42 CFR §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. F610 42 CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 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 12/5/2023 the California Department of Public Health made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about abuse. The facility failed to ensure Resident 2 was free from sexual abuse (non-consensual [not agreed by the people involved] sexual contact of any type with a resident) and failed to implement its policy and procedures (P&P) on Abuse Prohibition and Prevention Program and Sexual Abuse on 12/4/2023 at 8:10 a.m. when Resident 1 sat on Resident 2’s bed and touched Resident 2’s genitals while Resident 2 laid in bed as observed by Certified Nursing Assistant 1 (CNA 1) and as communicated by Resident 2. CNA 1 took Resident 1 to his bed and left the room to report the incident to Licensed Vocational Nurse (LVN 1) leaving Resident 2 unprotected from further abuse. LVN 1 after checking on both Residents 1 and 2, left the room with Resident 1 unattended in the same room with Resident 2. As a result, Resident 2 experienced non-consensual sexual contact from Resident 1 while under the care of the facility and was placed at risk for further abuse. Resident 2 conveyed he felt sexually assaulted, violated, and humiliated. A review of Resident 1’s Admission Record indicated the facility admitted the 67-year-old resident on 9/9/2023 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care-planning tool), dated 11/9/2023, indicated Resident 1 could understand and be understood, and had some memory problem. The MDS indicated Resident 1 required partial assistance with sit to stand, chair to chair transfer, and walking. A review of Resident 1’s Situational-Background-Assessment-Recommendation (SBAR, communication form between members of the health care team caring for a resident about his / her condition) Change of Condition (COC, a sudden clinically important deviation from a patient's baseline status), dated 12/4/2023, indicated CNA 1 reported that around 8:10 a.m., he witnessed Resident 1 sitting on Resident 2’s bed and inappropriately touching the top area of Resident 2’s incontinent brief. A review of Resident 1’s Care Plan, developed on 12/4/2023 for Resident 1’s involvement in a resident-to-resident inappropriate touching, indicated interventions including informing local law enforcement, monitoring for any signs of emotional distress, and offering a room change. A review of Resident 2’s Admission Records indicated the facility admitted the 70-year-old resident on 10/15/2021 with diagnoses including cerebral infarction (occurs because of disrupted blood flow to the brain which can cause parts of the brain to die off), dysarthria (difficulty speaking because the muscles for speech are weak), dysphagia (swallowing difficulties), and muscle weakness. A review of Resident 2’s MDS, dated 9/14/2023, indicated Resident 2 had memory problems and had the ability to understand and be understood. The MDS indicated Resident 2 required two-person assist with bed mobility and transfers and was unable to walk. A review of Resident 2’s SBAR COC form, dated 12/4/2023, Registered Nurse 1 (RN 1) documented CNA 1 reported that at around 8:10 a.m. he (CNA 1) witnessed Resident 1 sitting on Resident 2’s bed and inappropriately touching Resident 2’s incontinent brief area. The SBAR indicated RN 1 documented that when RN 1 attempted to interview Resident 2, Resident 2 did not want to talk. A review of Resident 2’s Care plan, developed on 12/4/2023 for Resident 2’s involvement in a resident-to-resident inappropriate touching, indicated interventions including monitoring Resident 2 for any signs of emotional distress, psychiatric consult (evaluation of the causes of emotional and for Social Services staff to provide emotional and psychosocial support. A review of Resident 2’s Social Services Progress Notes, dated 12/4/2023 timed at 8:47 a.m., indicated the Social Services Coordinator (SSC) completed an interview with Resident 2 with yes or no questions. The SS Progress Notes indicated Resident 2 was shaking at the start of the interview, but the shaking decreased as the interview progressed. Resident 2 was able to gesture he was touched over the incontinent brief. During an interview on 12/5/2023 at 10:33 a.m., Resident 1 stated that when (no date or time was specified) he was talking to his roommate (Resident 2), who did not speak but used his hands and gestures to communicate, he was accused of touching Resident 2 inappropriately. Resident 1 stated he only touched Resident 2’s leg and did not touch him inappropriately. On 12/5/2023 at 11:11 a.m., a concurrent observation and interview was conducted with Resident 2, who could only communicate with hand gestures and by nodding to indicate Yes and head shaking to indicate No. When asked about the incident with Resident 1 that occurred on 12/4/2023 at around 8:10 a.m., Resident 2 was observed pointing to the bed next to his (previously occupied by Resident 1) and to his own bed to indicate Resident 1 came to his bed. When asked if Resident 1 sat on his bed, Resident 2 nodded Yes. Resident 2 nodded Yes to the question of being touched inappropriately. Resident 2 proceeded to remove his blankets and demonstrated by placing his hand on top of his incontinent brief and motioning up and down, showing the Evaluator what Resident 1 did to him. Resident 2 gestured Resident 1’s hand was inside of his incontinent brief (directly over his genitals) when touching him. When asked if that was what Resident 1 had done to him, Resident 2 nodded Yes. When asked if he felt Resident 1 sexually assaulted him, Resident 2 nodded Yes. Resident 2 gestured CNA 1 came in the room and made Resident 1 go back to his bed. During an interview on 12/5/2023 at 12:14 p.m., CNA 1 stated that on 12/4/2023 at around 8 a.m. he was entering Residents 1 and 2’s room and observed Resident 1 sitting on Resident 2’s bed facing Resident 2. Resident 2 was lying down in bed facing up. CNA 1 stated Resident 2’s blanket was removed (was to the side), his gown was pulled up exposing his (Resident 22’s) abdomen, his incontinent brief was on, and Resident 1 was massaging Resident 2 over the private area on top of the incontinent brief. CNA 1 stated he did not observe skin-to-skin contact (hand directly touching Resident 2’s genitals). CNA 1 stated Resident 2 appeared upset, shaking his hands in attempts to push Resident 1 away. On 12/5/2023 at 1:06 p.m., during an interview, Resident 2 nodded Yes to feeling violated and humiliated. On 12/5/2023 at 1:15p.m., during an interview, the SSC stated that on 12/4/2023 after she was informed of the sexual abuse allegation, she went to speak to Resident 2 and observed Resident 2 to be excessively shaking but as the interview progressed, Resident 2’s shaking subsided. The SSC stated Resident 2 was shaky due to the alleged sexual abuse. The SSC stated she asked Resident 2 if he could confirm the incident of sexual abuse and Resident 2 nodded Yes and pointed to Resident 1 as the abuser. The SSC stated Resident 2 nodded Yes about Resident 1 touching him over the incontinent brief. On 12/5/2023 at 1:41 p.m., during an interview, RN 1 stated that on 12/4/2023 at 8:20 a.m. Licensed Vocational Nurse 1 (LVN 1) notified her about CNA 1’s report of sexual abuse from Resident 1 on Resident 2. RN 1 stated she went to speak to Resident 2 who confirmed Resident 1 touched him over his incontinent brief. During an interview on 12/5/2023 at 3:01 p.m., the DON stated Resident 1’s interaction with Resident 2 was inappropriate. A review of the current facility provided P&P titled, "Abuse Prohibition and Prevention Program,” revised 3/2023, indicated the facility has policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting abuse. To ensure protection for the health, welfare and rights of each resident residing in the facility; and to assure the facility is doing all that is within its control to prevent occurrences of abuse. A review of the current facility provided P&P titled, "Sexual Abuse,” revised 3/2023, indicated the facility conducts investigation and protects a resident from non-consensual sexual relations anytime the facility has reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent. Sexual abuse: Non-consensual sexual contact of any type with a resident. Unwanted intimate touching of any kind especially of breast or perineal (the area of the genitals) area. The facility failed to ensure Resident 2 was free from sexual abuse and failed to implement its P&P on Abuse Prohibition and Prevention Program and Sexual Abuse on 12/4/2023 at 8:10 a.m. when Resident 1 sat on Resident 2’s bed and touched Resident 2’s genitals while Resident 2 laid in bed as observed by CNA 1 and as communicated by Resident 2. CNA 1 took Resident 1 to his bed and left the room to report the incident to LVN 1 leaving Resident 2 unprotected from further abuse. LVN 1 after checking on both Residents 1 and 2, left the room with Resident 1 unattended in the same room with Resident 2. As a result, Resident 2 experienced non-consensual sexual contact from Resident 1 while under the care of the facility and was placed at risk for further abuse. Resident 2 conveyed he felt sexually assaulted, violated, and humiliated. The above violations had a direct relationship to the health, safety, or security of Resident 2.