Other·June 13, 2024

§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. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. F609 (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. § 72315 - 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. § 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 4/19/2024 the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging Resident 1 and Resident 2 had physical altercation. On 4/30/2024, CDPH conducted an unannounced visit to the facility to investigate the FRI allegations. Upon investigation, CDPH determined the facility did not protect Resident 1 from Resident 2’s physical abuse and facility did not report the abuse allegation to CDPH or State Long Term Care Ombudsman (a public advocate or residents of nursing homes, board and care homes and assisted living facilities). The facility failed to protect Resident 1 right to be free from physical abuse from Resident 2. The facility failed to: 1. Ensure Resident 1 and Resident 2 were separated and no longer continued to share the same room after a Certified Nursing Assistant (CNA 1) witnessed Resident 2 hitting Resident 1 on the face on 4/13/2024. 2. Ensure the Registered Nurse (RN 1) separated Resident 1 and Resident 2 and did not let them to continue to share the same room after RN1 received the report on 4/15/2024 with allegation of physical abuse to Resident 1. 3. Ensure an allegation of abuse was reported to CDPH or State Long Term Care Ombudsman or the police department within two hours of the occurrence of incident and no later than 24 hours for Resident 1. As a result, Resident 1 was placed at risk for future abuse and had the potential to cause feelings of intimidation, neglect and not feeling safe in the facility which was considered their home and had the potential to result in unidentified abuse in the facility and had the potential for Resident 1 to experience further abuse from Resident 2 Findings: A review of Resident 1’s Admission Record, indicated Resident 1, a 82 year old female, was admitted to the facility on 12/12/2023, with diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), transient ischemic attack ([TIA] a short period of symptoms similar to those of a stroke), and heart failure ( a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs). A review of Resident 1’s History and Physical (H&P), dated 12/13/2023, the H&P indicated Resident 1 had a decision-making capacity. A review of Resident 1’s Minimum Data Set ([MDS], a comprehensive assessment and care screening tool]) dated 3/19/2024, indicated, Resident 1 required partial/moderate (helper does less than half the effort) assist with chair/bed-to-chair transfer, toilet transfer and had utilized a wheelchair as a mobility device. A review of Resident 2’s Admission Record, indicated Resident 2, an 89-year-old female admitted to the facility on 2/15/2024, with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities) and uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional). A review of Resident 2’s MDS dated 2/22/2024, indicated, Resident 2 required dependent (helper does all the effort) for chair/bed-to-chair transfer, showering, toileting, and had utilized a wheelchair and walker as a mobility device. During an interview on 4/30/2024 at 8:31 a.m., Resident 1 became agitated when asked about the incident. Resident 1 stated she does not want to discuss incident of Resident 2 hitting her. Resident 1 stated the incident happened a long time ago and does not want to discuss it. Resident 1 stated it was Resident 2 who hit her and does not remember exactly when the incident occurred. Resident 1 stated Resident 3 (roommate) witnessed the incident. During an interview on 4/30/2024 at 8:35 a.m. with Resident 3 Resident 3 stated she witnessed Resident 2 hitting Resident 1 on the face. Resident 3 stated she does not want to discuss the incident any further because it makes Resident 1 upset. During a phone interview on 4/30/2024 at 8:47 a.m., Resident 1 ‘s RR stated the facility informed her on 4/14/2024 that when Resident 1 was coming out of the restroom with CNA 1’s assistance, Resident 2 allegedly slapped Resident 1 on the face. RR stated Resident 1 told her CNA 1 witnessed the incident. RR stated CNA 1 was in Resident 1’s room at the time that she (RR) was speaking to Resident 1. RR stated she spoke to CNA 1 on Resident 1’s cell phone and asked CNA 1 if she witnessed the incident between Resident 1 and Resident 2 and CNA 1 stated “yes.” RR stated CNA 1 informed she would report the incident to the charge nurse. RR stated she called the facility on 4/15/2024 to report the incident and spoke to the Social Service Director (SSD). RR stated she was informed by SSD that the facility will initiate an investigation regarding the alleged incident. A review of Employee/Resident Statement dated 4/16/2024, the Employee/Resident Statement indicated, Resident 1 stated she wants Resident 2 out of her room. During an interview on 4/30/2024 at 9:52 a.m. CNA 1 stated that the incident occurred a few weeks ago but could not recall the exact date. CNA 1 stated she was assisting Resident 1 out of the restroom and noticed Resident 2 was aggressively moving the privacy curtain. CNA 1 stated that she was assisting Resident 1 into her wheelchair. CNA 1 stated she noticed Resident 2’s voice was aggressive in tone (speaking loudly) and Resident 2 appeared extremely agitated. However, she (CNA1) could not understand Resident 2 because she was speaking in a different language than commonly spoke English. CNA 1 stated Resident 1 was sitting in her wheelchair in between Resident 1’s and Resident 2’s bed. CNA 1 stated she witnessed Resident 2 hitting Resident 1 on her right arm. CNA 1 stated Resident 2 was swinging her arms aggressively so she (CNA 1) blocked Resident 2 from hitting Resident 1 again by moving Resident 1 back into the restroom. CNA 1 stated after the incident she informed LVN 1 of the incident. CNA 1 stated she informed LVN 1 that Resident 2 was behaving aggressively and refusing to be showered. CNA 1 stated LVN 1 went to speak to Resident 2, however, she (CNA 1) was not present during the conversation. CNA 1 stated the residents were not separated after the incident on 4/13/2024 and remained in the same room. During an interview on 4/30/2024 at 10:00 a.m., the SSD stated he was informed of the alleged incident on 4/16/2024 by the administrator. The SSD stated he was informed that Resident 1 was hit by Resident 2. The SSD stated he conducted an assessment for both residents and interviewed Resident 1 and Resident 1 stated Resident 2 hit her on the cheek. The SSD stated Resident 1 told him CNA 1 was assisting her out of the restroom when she saw Resident 1 pulling the privacy curtain and she (Resident 1) attempted to stop Resident 2 from pulling the privacy curtain. Resident 1 stated that was when Resident 2 hit her on her on a cheek. The SSD stated Resident 1 first stated Resident 2 hit her on one cheek and then stated she was hit on both cheeks. The SSD stated he reported the incident to the Ombudsman on 4/16/2024, three days after the incident on 4/13/2024. The SSD stated both residents should have been separated immediately to avoid further harm to Resident 1 and ensure safety. The SSD stated Resident 2’s room was changed on 4/16/2024 due to Resident 1 was hit by Resident 2. The SSD stated abuse should be reported immediately upon knowledge of the allegation. The SSD stated abuse should be reported to the administrator immediately and the residents should be separated immediately to avoid further harm to the resident (in general) and ensure the residents safety. During an interview on 4/30/2024 at 10:26 a.m. the License Vocational Nurse (LVN 1) stated the alleged incident occurred over the weekend but did not remember the exact date. LVN 1 stated CNA 1 reported to her Resident 2 was aggressive and refusing to shower. LVN 1 stated that CNA 1 did not report Resident 2 hit Resident 1 at that time. LVN 1 stated she did not report to the Registered Nurse Supervisor (RNS) or Resident 2’s physician that CNA 1 informed her Resident 2 was exhibiting aggressive behavior. LVN 1 stated a completion of change in condition (a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) form should be considered when residents (in general) are exhibiting aggressive behavior and refusing care. LVN 1 stated RNS and the doctor should be informed immediately when there was a change of condition because the doctor could further assess the resident (in general) and implement interventions if necessary. LVN 1 stated the report by CNA 1 that Resident 2 exhibited aggressive behavior would be considered a change in condition and should have been reported to the RNS and Resident 2’s physician at that time. LVN 1 stated Resident 1 and Resident 2 should have been separated immediately when there was allegation of physical abuse to protect the residents from further abuse. LVN 1 stated residents (in general) could feel afraid and be fearful if the resident (in general) were still in the presence of a resident who just hit them. A review of Resident 2’s Care Plan, titled “Episode of being resistive to care as evidenced attempting to strike out during care and medication administration,” dated 4/2024 indicated one of the interventions included to monitor resident behavior for any changes or improvements and to notify medical doctor of refusal of care. During a concurrent interview and record review on 4/30/2024 at 10:50 a.m. with RNS 1, the RNS 1 stated the incident occurred on 4/13/2024. RNS1 stated she was made aware of the incident the next working day during hand off on 4/16/224 from RNS 2. RNS 1 stated she was informed Resident 1 alleged Resident 2 slapped her in the face. RNS 1 stated she notified the administrator, and the investigation was started on 4/16/2024. RNS 1 stated she did not move Resident 2 to another room immediately because Resident 2 was asleep, and she (RNS 1) did not feel that residents were unsafe, so she made the judgement call to leave Resident 2 in the same room with Resident 1. RNS 1 stated Resident 1 and Resident 2 should have been separated immediately to avoid the incident from reoccurring and keep the residents safe. RNS 1 stated by not separating both residents and let him share the same room could have made Resident 1 felt afraid and threaten. RNS 1 stated Resident 2 was moved to another room on 4/16/2024, three days after the incident on 4/13/2024. RNS 1 stated residents (in general) should be separated immediately after an altercation to protect the residents (in general) from future abuse. RNS 1 stated Resident 1 has the right to feel safe in her room and should be free from any type of abuse. Resident 2’s Nurses Progress Notes were reviewed, and RN 1 confirmed Resident 2 room change did not occur until 4/16/2024. During a concurrent interview and record review on 4/30/2024 at 11:30 a.m. with Director of Staff Development (DSD), the DSD stated residents (in general) should be separated immediately after a report of abuse whether it is actual or alleged in order to prevent the abuse to continue and to ensure the residents (in general) safety. The DSD stated abuse with an injury should be reported within two hours and without injury within 24 hours to the abuse coordinator, CDPH, police, and Ombudsman. During a concurrent interview and record review on 4/30/2024 at 12:27 p.m. with the Director of Nursing (DON), the DON stated that RN 2 made her aware of the alleged incident on 4/15/2024. The DON stated RN 2 informed her that Resident 1’s RR informed her that on 4/13/2024 Resident 2 hit Resident 1 in the face. The DON stated she informed RN 2 to perform a physical assessment (a series of services that are provided to evaluate an individual's medical history and present physical condition) and pain assessment (designed to measure pain) for Resident 1 and begin the investigation. The DON stated when abuse was reported staff should separate both residents immediately because it potentially placed Resident 1 at risk for future abuse and harm. The DON stated the incident with Resident 1 and Resident 2 should have been reported immediately to CDPH, Ombudsman and the police. The DON stated both residents should have been separated to avoid the potential for the abuse to occur again. The DON stated the delay in moving Resident 2 to another room placed Resident 1 at risk for future abuse and harm. The DON stated the abuse coordinator, CDPH, Ombudsman, police, the physician, and resident representative should be notified immediately. The DON stated CDPH should be notified within 24 hours if there was no injury. The DON stated the facility did not report the incident between Resident 1 and Resident 2 to CDPH, Ombudsman and police as required. During an interview on 4/30/2024 at 1:02 p.m. the Administrator (Admin) stated RN 2 informed her of the incident during the night on 04/15/2024. Admin stated RN 2 informed her that Resident 1’s daughter reported Resident 2 hit Resident 1 in the face. Admin stated Resident 1’s daughter informed RN 2 that she thought CNA 1 reported the incident to LVN 1. Admin stated, when she was informed about the incident, she was told by RN 2 that Resident 1 and Resident 2 were sleeping at that time. Admin stated she instructed RN 2 to continue to let Resident 1 and Resident 2 sleep and move Resident 2 out of the shared room with Resident 1 the next day 4/16/2024. Admins stated Resident 1 and Resident 2 should have been separated immediately after abuse allegation occurs for safety re