Health inspection·May 25, 2023

§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 CR § 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 3/8/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation regarding a sexual abuse incident. The facility failed to protect the residents' right to be free from physical abuse and sexual abuse for two of five sampled residents (Residents 2 and 3) by failing to: 1. Protect Resident 3 who was threatened by his roommate (Resident 1) on 3/2/2023 with a butter knife. 2. Ensure Resident 1 was not found in Resident 2's bedroom on 3/7/2023 on top of Resident 2, who was developmentally delayed (someone who have not gained the developmental skills expected of him or her, compared to others of the same age) and whose incontinence briefs and pants were observed at her ankle. Resident 1's private part (the genital organs of the male) was observed exposed. 3. Provide the required staffing personnel including providing a Certified Nursing Assistant (CNA) to Resident 2 and a one-to-one sitter (staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act) to Resident 2 as indicated in Resident 2's care plan. 4. Assess and revise Resident 1's care plan to identify the potential risks to other residents related to the behaviors of Resident 1 who had a known history of sexually inappropriate behaviors. As a result, Resident 2 experienced sexual abuse and severe psychosocial harm because of the sexual abuse. Resident 2 was found grimacing, crying, and change in behavior of not leaving her bed and not moving out of her bed. And Resident 3 experienced mental anguish, and who stated that he was fearful every time he saw Resident 1 in the hallway after the incident. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on 12/23/2022 with diagnoses that included fracture of the right tibia (the shinbone, the larger of the two bones in the lower leg), multiple fractures of the ribs, hypertension (high blood pressure) and history of cerebral infarction (stroke, brain tissue damage due to a blood clot or bleed in the brain). A review of Resident 1's Clinical Admission Evaluation, dated 12/23/2022, indicated Resident 1 was alert and oriented (being aware of person, place, time and/or situation), communicated verbally, speech was clear and was able to understand and be understood when speaking. A review of Resident 1's Change in Condition (CIC / COC) Evaluation, dated 3/2/2023, indicated Resident 1 had a change in behavior of threatening his roommate (Resident 3). The COC indicated that Resident 3 (Resident 1's roommate) came to the nursing station alleging that Resident 1 wanted to hurt him with a butter knife. Licensed Vocational Nurse 3 (LVN 3) checked on Resident 1 in his room and found Resident 1 holding a butter knife. The note indicated Resident 1 admitted to hurting Resident 3 because he was tired of Resident 3 making noises in the middle of the night. The note indicated Resident 1 only agreed to hand over the knife when LVN 3 told him Resident 3 will be moved to a different room. A review of Resident 1's psychiatric note, dated 3/2/2023, indicated Resident 1 has a history of schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood) and anxiety (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities). The note indicated Resident 1 was being evaluated for recent involvement in an altercation (threaten his roommate with a butter knife). The note indicated "Upon further evaluation, patient present increased in agitation and observed Responding to Internal Stimuli (RTIS, a process that involves responding to one's own emotions and physical sensations)." A review of Resident 1's SNF (Skilled Nursing Facility) Hospital Transfer Form, dated 3/2/2023, indicated Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) secondary to physical and verbal aggression toward others. A review of Resident 1's Physician orders, dated 3/2/2023, indicated to transfer Resident 1 to GACH 1 for psychiatric evaluation and management of self-endangerment and to others. A review of Resident 1's Progress Note, dated 3/3/2023, indicated Resident 1 came back from GACH 1. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility on 1/24/2023 with diagnoses that included paranoid schizophrenia (a serious mental disorder in which people interpret reality abnormally), chronic obstructive pulmonary disease (COPD, group of lung disease that block airflow and make it difficult to breathe), muscle weakness, lack of coordination, difficulty in walking and anxiety. A review of Resident 3's Minimum Data Set (MDS - a standardize assessment and screening tool), dated 1/31/2023, indicated Resident 3 has intact thought process. A review of Resident 3's Change in Condition (CIC / COC), dated 3/2/2023, indicated Resident 3 is alert, oriented and able to make needs known. The COC indicated that Resident 3 reported to the charge nurse "my roommate (Resident 1) suddenly became aggressive to me. I'm just here in bed lying down." A review of Resident 3's Care Plan titled "Resident had physical aggression from a roommate," dated 3/2/2023, indicated a goal that resident will feel safe with continuous stay in the facility. During an interview on 3/8/2023 at 1:20 pm, Resident 3 stated Resident 1, his previous roommate threw things at him including glass and pitchers, unprovoked which hit him in the hand and left him with a scratch. Resident 3 stated he informed a nurse for the second time about Resident 1's behavior after which he was moved and transferred to a different room. Resident 3 stated when he sees Resident 1 in the hallway, he (Resident 1) scares him. Resident 3 was not able to state the day the incident occurred. During an interview on 3/8/2023 at 3:56 pm, the DON stated and confirmed that they found Resident 1 to be keeping butter knives in his room on 3/2/2023 including a butte knife hidden in the frame of his bed. During an interview on 3/9/2023 at 3:57 pm, LVN 2 stated and confirmed she was the one who called the police on 3/2/2023 around 8:15 am regarding the altercation between Resident 1 and Resident 3. LVN 2 stated she observed Resident 3 with a "small little abrasion on his hand, but we could not tell where it came from." LVN 2 stated and confirmed that after the incident between Resident 1 and Resident 3, the facility informed the kitchen staff to not put metal utensils on Resident 1's (meal tray). During an interview on 3/10/2023 at 2:59 pm, LVN 3 stated that on 3/2/2023 around 6 am in the morning, Resident 3 approached her and stated his roommate is trying to hurt him. LVN 3 stated she immediately went to Resident 3's room and found Resident 1 with a butter knife silverware on his left hand. LVN 3 asked Resident 1 to give her the knife and Resident 1 did. LVN 3 returned to the nursing station and assisted Resident 3 back to his room to get his belongings because he will be moved to another room. Upon return to the same room, LVN 3 stated he observed Resident 1 holding another knife. LVN 3 stated she told Resident 1 that if he does not give her the knife, she will call the police. Resident 1 handed LVN 3 the knife. Resident 3 was moved to another room. A review of the Progress Note, dated 2/2/2023, indicated "Seen resident (Resident 1) fondling and touching his self in front of the public staff." A review of Resident 2's Admission Record indicated Resident 2 was originally admitted to the facility on 1/19/2023 and re-admitted on 2/3/2023 with diagnoses that included cerebral palsy (a congenital disorder caused by abnormal brain development, often before birth, that causes problems with movement, posture, and balance.), autistic disorder (a developmental disability caused by differences in the brain manifested by problems with social communication and interaction, and restrictive or repetitive behaviors or interest), schizoaffective disorder, cognitive communication deficit (difficulty in thinking and use of language), restlessness and agitation. A review of Resident 2's History and Physical form, dated 2/3/2023, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2's Health Status Note by Registered Nurse Supervisor 1 (RN 1), dated 2/3/2023 indicated "due to constant roaming, wandering aimlessly, hoarding, collecting whatever she can grab in her hand she collected it kept to herself, dietary staff informed on how to help her maintain her functional weight offering mostly her food in a cup easy for her to grab on because she is always busy with her hands. Provided a 1:1 sitter for the resident effective today for close watch observation." A review of the Behavior Note by RN 1, dated 2/7/2023, indicated Resident 2 "wandered around in her room roaming aimlessly nonverbal communicates by facial and hand gestures, reported by staff that resident at times goes to closet hid herself as per her sitter 1:1 assigned..." A review of Resident 2's MDS, dated 2/10/2023, indicated Resident 2 has impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS also indicated Resident 2 needed supervision with bed mobility, limited assistance (resident highly involved in activity but staff provide guided maneuvering of limbs or other non-weight bearing assistance) with transfer, walking and eating and extensive assistance (resident involved in activity but staff provide weight-bearing support) in dressing, toilet use and personal hygiene. A review of Resident 2's Care Plan titled "The resident is/has potential to be physically aggressive related to anger, depression (persistent feeling of sadness and loss of interest), history of harm to others, poor impulse control," dated 2/17/2023 indicated the facility "provided a sitter 1:1 to closely monitor wandering behavior of resident to ensure safety." A written and signed statement by CNA 1, dated 3/7/2023, indicated "Around 1:30 am I was walking around doing my rounds on my patients. I walked in (room deducted, Resident 2's room) to check on (name deducted, Resident 2's name), making sure she was still sleeping. I wasn't assigned to her, but since I was walking by, I decided to check on her. I witnessed (deducted Resident 1's name) on top of (deducted Resident 2's name) hampering her. I was standing there in shock, so I walked to (deducted LVN 1's name) the LVN and told him to come to (deducted Resident 2's room) immediately. We walked back in the room and (deducted LVN 1's name) told (deducted Resident 1's name) to get off her. (Deducted Resident 1's name) got up with her, male genitalia all out (exposed). (Deducted Resident 2's name) incontinence briefs and pants were at her ankles. (Deducted Resident 1's name) walked back to his room with his male genitalia all out still. (Deducted Resident 2's name) pulled back her incontinence briefs and pants. After I reported the situation, I went to answer my call lights that was on. Before the situation occurred, I was checking on (Deducted, Resident 2's name) every hour and she was sleeping." A review of Resident 1's Change in Condition (CIC, COC) Evaluation, dated 3/7/2023 at 6:48 am but signed on 3/8/2023 by LVN 1, indicated Resident 1's change in behavior of "sexual assault towards peer." The COC indicated "Patient was found lying on top of a female patient in her room. He was asked to get up and go back to his room form one of the charge nurses. As he was walking away, he was noticed to be fully clothed (pants on at waist and buttoned, shirt on, and jacket on. His genitals were out of his pants through his zipper. Recipient (Resident 2) was noted to be fully clothed (pants and incontinence briefs on, and shirt on." A record review of the Progress Note by Registered Nurse Supervisor (RN 1), dated 3/7/2023 at 1:28 pm, indicated that on 3/7/2023 at 11 am, three police officers visited Resident 1 but Resident 1 pretended to be asleep and did not respond to the officers' questions. The note indicated that on 3/7/2023 at 12:20 pm, two police officers handcuffed Resident 1. The note indicated "He (Resident 1) went quietly with no words ambulated with his shoes on accosted by 2 police officers to transport him to (deducted hospital name, GACH 2) via police car." A review of Resident 2's Health Status Note by RN 1, dated 3/7/2023 at 2:24 pm, indicated that on there was a report of alleged incident on sexual assault regarding Resident 1 and Resident 2. RN 1 indicated that she was unable to illicit (get) information from Resident 2 due to Resident 2's medical history of autism (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), cerebral palsy, and developmental delay. RN 1 indicated in her note that on 3/7/2023 at 9:20 am, the Fire Department (FD) "came surprisingly stating someone had call 911 on behalf of the resident." The note indicated the paramedics transported the resident (Resident 2) to General Acute Care Hospital 2 (GACH 2) for further evaluation 0n 3/7/2023. A review of Resident 2's Physician Order, dated 3/7/2023, indicated an order to transfer Resident 2 to GACH 2 for medical evaluation and management related to alleged sexual assault incident. A review of Resident 1's Progress Note by RN 1, dated 3/7/2023 at 6:27 pm, indicated Resident 1 returned from GACH 2 with 2 police officers and was led to the conference room to be interviewed by two detectives. The note indicated Resident 1 was provided a 1:1 sitter after return to the facility. A review of Resident 2's Health Status Note by RN 1, dated 3/7/2023 at 6:44 pm, indicated Resident 2 returned to the facility from GACH 2 on 3/7/2023 at 6 pm and was provided a 1 on 1 sitter. A review of Resident 1's Physician Orders, dated 3/7/2023, indicated an order to transfer Resident 1 to GACH 1 for "psychiatric evaluation and management of self-endangerment and to others and alleged sexual assault." A review of Resident 1's Care Plan titled "Resident had an attempted sexual aggression towards another resident," dated 3/7/2023, indicated goal of "resident will have no episode of sexual aggression through next review date." A review of Resident 2's Care Plan titled "Resident had an attempted sexual aggression from another resident," initiated on 3/7/2023, indicated a goal of "resident will feel safe in her continued stay in the facility." Interventions included in the care plan are to check on resident whereabouts, frequent visual checks, providing a one-on-one sitter to resident, providing a safe and secure environment, psychiatry consultation and psychology consultation. A review of Resident 2's Care Plan titled "Resident at risk for psychosocial well-being problem related to S/P (status post, after) incident with another resident," initiated on 3/7/2023, indicated a goal of "resident will develop effective coping skills through review date." Interventions included in the care plan are to anticipate resident needs, frequent visual checks, one to one sitter as possible, provide resident activities and encourage resident to participate in daily activities. A review of the Change in Condition Evaluation on Resident 2, dated