Other·June 28, 2024

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. CFR §483.12(a) The facility must- CFR §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; CCR22§ 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. CCR22 § 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. CCR22 §72521 - Administrative Policies and Procedures (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. On 5/8/2024, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) alleging staff to resident abuse. On 6/15/2024 at 9:10 a.m., CDPH conducted an unannounced visit at the facility to investigate the allegation. Upon investigation, CDPH determined the facility failed to ensure Resident 1 was free from physical abuse. The facility failed to: 1. Ensure a Certified Nurse Assistant (CNA 3) did not slap Resident 1's left forearm. 2. Ensure the Registered Nurse Supervisor (RNS) immediately separated Resident 1 from CNA 3 after the incident to prevent further abuse by CNA 3. 3. Ensure RNS did not allow CNA 3 to complete Resident 1's bed bath after CNA 3 slapped the resident's forearm thus placing Resident 1 at risk for further abuse. 4. Ensure CNA3 and RNS followed the facility policy and procedure (P&P) titled, "Abuse & Neglect Prohibition," and protected Resident 1's right to be free from mistreatment and physical abuse. This deficient practice placed Resident 1 at risk to be subjected to further abuse by CNA 3 and had the potential to cause Resident 1 to feel intimidated fearful and neglected, and not feeling safe in the facility. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on 2/15/2024 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities) without behavioral disturbance (a persistent and repetitive pattern of behavior that can create distress in others at risk), unsteady gait (manner of walking), and anxiety (a feeling of worry, nervousness, unease, typically about an imminent event or something with an uncertain outcome. A review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 2/22/2024, indicated Resident 1 had severe impairment in cognitive (ability to make decisions of daily living) skills for daily decision-making and required substantial /maximum assistance from staff (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort with personal hygiene, lower body dressing [the ability to dress and undress below the waist, including fasteners; does not include footwear]), put on and take off footwear. A review of Resident 1's change of condition ([COC] - documentation of any sudden change from the Resident's baseline) note dated 5/7/2024 and timed at 12:37 a.m., indicated CNA 2 reported to the RNS that someone was hitting Resident 1. The COC indicated the Registered Nurse Supervisor (RNS) entered Resident 1's room and found Resident 1 agitated and screaming as she was receiving a bed bath from CNA 3. The COC indicated the RNS witnessed CNA 3 slapping Resident 1's left forearm. During an interview on 5/15/2024 at 3:35 p.m., CNA 2 stated on 5/8/2024 as she was passing by Resident 1's room she heard a slapping motion behind Resident 1's privacy curtain. CNA 2 stated she immediately reported to the RNS what she heard. CNA 2 stated the RNS and her went to Resident 1's room and saw CNA 3 was giving Resident 1 a bed bath. CNA 2 stated she heard the RNS ask for another nurse to assist CNA 3 to complete the resident's care since Resident 1 was agitated. During an interview on 5/15/2024 at 4:35 p.m., CNA 3 stated on 5/8/2024, Resident 1 was heavily soiled with excrement (solid waste that is passed out of a person's body) and vomit (matter from the stomach). CNA 3 stated she proceeded to clean Resident 1. CNA 3 stated Resident 1 was upset and flailing her arms and saying "who are you?" CNA 3 stated "when I turned Resident 1 towards me, Resident 1 slapped me." CNA 3 stated "I told Resident 1 to stop hitting me." CNA 3 stated the RNS entered Resident 1's room and witnessed Resident 1 being agitated and screaming while "I was trying to clean the resident." CNA 3 stated "the RNS witnessed me slapping Resident 1's left forearm after she (Resident 3) slapped me." CNA 3 stated "I then apologized to Resident 1 and the RNS." CNA 3 stated the RNS got her help from another staff member and instructed her (CNA 3) to finish cleaning Resident 1. CNA 3 stated she finished with Resident 1 and was able to finish caring for two more residents before she left the facility that day. CNA 3 stated she tried to take care of the situation, but realized it was the wrong thing to do. During an interview on 5/15/2024 at 5:45 p.m., the Administrator (ADM) stated when a suspected abuse allegation is reported we separate the abuser from the victim immediately or as soon as we find out the facility staff was hurting the resident, to prevent further harm. The ADM stated the facility reports the abuse allegation to CDPH and other authorities within two hours. The ADM stated every staff is a mandated reporter. During an interview on 5/16/2024 at 11:19 a.m., the RNS stated on 5/8/2024 when she arrived in Resident 1's room the resident was agitated. The RNS stated she observed CNA 3 while cleaning Resident 1 CNA 3 slapped Resident 1's left forearm. The RNS stated she then called another CNA to help complete Resident 1's care while she (RNS) observed the completion of the daily care task. The RNS stated letting CNA 3 continue to care for Resident 1, after she witnessed CNA 3 slapping Resident 1's left forearm "was the wrong thing to do." The RNS stated "I should have stopped the care and separated CNA 3 from Resident 1 immediately." The RNS stated by not removing CNA 3from Resident 1 could allow CNA 3 to continue slapping Resident 1 and placing Resident 1 in harm's way. During an interview on 5/16/2024 at 5:45 p.m., the Director of Nursing (DON) stated the RNS should have separated CNA 3 from Resident 1 immediately and not allowed CNA 3 to continue to provide care to Resident 1. The DON stated the residents' safety always comes first. A review of the facility's policy and procedure (P&P) titled, "Abuse & Neglect Prohibition," dated 2017, indicated "Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property." A review of the facility's undated job description titled "Registered Nurse Supervisor" indicated, monitor nursing care to ensure that all residents are treated fairly, with kindness, dignity, and respect. These violations presented a direct or immediate relationship to the health, safety, security, or welfare of the residents.