Health inspection·September 5, 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. 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. 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. On 7/26/2024, 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 protect Resident 2's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm). On 7/14/2023, at 6:33 p.m., Resident 1 hit Resident 2 on the back of the shoulder. Resident 2 was sitting in his wheelchair and Resident 1, rushed over to Resident 2's wheelchair, and hit Resident 2 several times on the back of the left neck and left shoulder. As a result, Resident 2 was subjected to physical abuse by Resident 1 while under the care of the facility. Resident 2 sustained abrasion (scratches or scrapes) to his left shoulder and felt soreness to the neck. The facility transferred Resident 2 to the general acute care hospital (GACH) for further care and evaluation. During a review of Resident 1's Admission Record indicated the facility initially admitted the 31-year-old male resident on 11/16/2023 with a readmission date of 7/8/2024. Resident 1's diagnoses included major depressive disorder (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act), psychoactive substance abuse (a strong desire or sense of compulsion to take a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), and suicidal ideations (wanting to take one's own life). During a review of Resident 1's History and Physical, dated 7/11/2024, indicated the resident had the capacity to understand and make decisions. During a review of Resident 1's Change in Condition Evaluation (COC), dated 7/14/2024 at 6:40 p.m., indicated that on 7/14/2024 at 6:33 p.m. Resident 1 was seen hitting Resident 2. The COC indicated Registered Nurse 1 (RN 1) immediately separated the two residents, and Resident 1 was aggressive and tried to hit RN 1. During a review of Resident 2’s Admission Record indicated the facility initially admitted the 83-year-old male resident on 4/26/2022 and readmitted on 12/31/2023 with diagnoses including hypertension (HTN- high blood pressure) and low back pain. During a review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/20/2024, indicated the resident's cognitive skills (ability to understand and make decisions) were intact (not affected). The MDS indicated Resident 2 required supervision or touching assistance for eating and oral hygiene. The MDS indicated Resident 2 required moderate assistance with dressing, and substantial/maximal assistance with transferring, showering, and toilet and personal hygiene. During a review of Resident 2's Change in Condition Evaluation, dated on 7/14/2024 and timed at 6:40 p.m. indicated Resident 1 ran towards Resident 2 and began attacking Resident 2 with an unknown object to the back of the neck. RN 1 immediately intervened and separated Resident 2 from Resident 1. Resident 1 ran out of the room. During a review of Resident 2's Order Summary Report, dated on 7/14/2024, indicated Resident 2 may be sent out of the facility for further evaluation. During a review of Resident 2's Nursing Notes, dated 7/14/2024 and timed at 10:50 p.m., indicated Resident 2 returned to facility from the GACH at 10:50 p.m. Resident 2 was noted to have abrasions to back of neck and left chest area, the abrasions clean and open to air, and Resident 2 denied pain. During a review of Resident 2's Care plan, dated on 7/14/2024, indicated Resident 2 was involved in a physical altercation with Resident 1. The care plan indicated Resident 2 was struck by roommate resulting in abrasion to left shoulder. During a review of Resident 2's Wound Weekly Monitoring Assessment, dated 7/15/2024, indicated Resident 2 had left shoulder front abrasions measuring 3.1 centimeters (cm - a unit of measurement) by length, 0.5 cm by width, and 0 cm by depth. During a review of facility's investigation report, dated 7/19/2024, indicated Resident 1 turned around and attacked his roommate, Resident 2. RN 1 jumped in and separated them and made sure Resident 1 then got in his wheelchair and he began rolling out of facility. The report indicated Resident 2 felt soreness to the neck. During an interview on 7/26/2024 at 11:31 a.m., Resident 2 stated that he had been in the facility for nine months, never had any resident attack him before a week ago. Resident 2 stated he had never had any interactions with his roommate (Resident 1) before last week. Resident 2 stated that he was sitting looking at his television and the next thing he knows, a man (Resident 1) hit him in the back on the left shoulder, three or four times and the left side of his neck. Resident 2 stated that the nurse (RN 1) came and got Resident 1 off him very quickly. Resident 2 stated that he had no pain from the man hitting him. Resident 2 stated that the nurses (names not identified) looked at him and made sure he was ok, and the ambulance came immediately and took him to the hospital. He stated that the hospital did an X-ray, and he came back to the facility the same night. Resident 2 stated he did not see Resident 1 again because Resident 1 was taken immediately to jail after the incident (physical abuse) happened. During an interview on 7/26/2024, at 11:44 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that on 7/14/2024, around 6:30 p.m., RN 1 removed Resident 1 and he (Resident 1) went back to his wheelchair and then ran to Resident 2 and began hitting Resident 2's neck. RN 1 separated him (Resident 1) from Resident 2 and then Resident 1 went out of the room into the hallway. During an interview on 7/26/2024 at 1:21 p.m., Registered Nurse 1 stated that on 7/14/2024 at around 6:30 p.m. suddenly Resident 1 turned and went towards Resident 2 and grabbed Resident 2 and she went and pulled Resident 1 off Resident 2 and then Resident 1 went out of the room and LVN 1 and LVN 2 followed Resident 1 in the nursing station. RN 1 stated she assessed Resident 2, and he had no pain, she offered pain medication and he refused. RN 1 stated that both residents were transferred out of the facility within 10 minutes. RN 1 stated that abuse should never happen in the facility because we have to protect the residents. During an interview on 7/26/2024 at 3:35 p.m., the Administrator (ADM) stated that the outcome of his investigation was that Resident 1 had become psychotic and caused him to attack Resident 2. The ADM stated that abuse should never occur in the facility, the facility is supposed to protect everyone from any abuse ever happening. During a review of the current facility-provided policy and procedure (P&P) titled, "Abuse, Neglect, & Exploitation of Residents & Property," revised 3/2023, indicated the facility's policy, "The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident; family members or legal guardians, friends, or other individuals." The facility failed to protect Resident 2's right to be free from physical abuse. On 7/14/2023, at 6:33 p.m., Resident 1 hit Resident 2 on the back of the shoulder. Resident 2 was sitting in his wheelchair and Resident 1, rushed over to Resident 2's wheelchair, and hit Resident 2 several times on the back of the left neck and left shoulder. As a result, Resident 2 was subjected to physical abuse by Resident 1 while under the care of the facility. Resident 2 sustained abrasion to his left shoulder and felt soreness to the neck. The facility transferred Resident 2 to the GACH for further care and evaluation. The above violations had a direct relationship to the health, safety, or security of Resident 2.