Health inspection·November 8, 2024

F550 §483.10(a) Resident Rights The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. 72523 (a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 9/23/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 2) reported that she was assaulted by a Certified Nursing Assistant (CNA 1), who lifted her from a chair instead of using a mechanical lift (a device designed to help caregivers move a resident from a sitting to a standing position and from one place to another), and per CNA 1, may have held her too tight, causing bruising to both of her arms. On 9/23/2024, CDPH conducted an unannounced visit to the facility to investigate the complaint allegation. Upon investigation, it was determined that CNA 1 picked Resident 2 up from a geriatric chair ([Geri chair] a large, padded reclining chair that provides support and comfort for people with limited mobility) to put her in bed against her wishes. The facility failed to: 1. Ensure CNA 1 honored Resident 2's decision not to go back to bed and did not force her against her wishes back to bed by holding her arms tightly, which resulted in Resident 2 becoming combative as she resisted CNA 1's attempt to place her back in bed. 2. Ensure CNA 1 and Registered Nurse Supervisor 1 (RNS 1) followed the facility's policy and procedure (P&P) titled, "Activities of Daily Living (ADLs), Supporting," which indicated if a resident resist or refused care, staff would consider approaching the resident in a different way or at a different time or having another staff member speak with the resident. 3. Ensure CNA 1 and RNS 1 followed the facility's P&P titled, "Requesting, Refusing and/or Discontinuing Care or Treatment," which indicated residents have the right to refuse and/or discontinue treatment and was not forced to accept any care or treatment. These deficient practices resulted in Resident 2 becoming combative, when she was forced into bed against her wishes, while her arms were held tightly by CNA 1, causing bruises on her mid right forearm and right hand, and a skin tear on her right hand by the thumb, that measured approximately 2.0 centimeters (cm) long. A review of Resident 2's Admission Record (Face Sheet), indicated Resident 2 was initially admitted to the facility on 10/21/2020 and re-admitted on 2/20/2024, with diagnoses including functional quadriplegia (the complete inability to move due to severe disability but without injury to the brain or spial cord), spinal stenosis (a narrowing of the spinal canal in the lower back that can put pressure on the spinal cord and nerves) of the lumbar region, a displaced traverse fracture of the shaft of the right tibia (a break in the shinbone where the bone pieces moved out of alignment, creating a gap), a displaced fracture of the lateral condyle of the left tibia (a break in the bone on the outside of the shin near the knee), and neuromuscular dysfunction of the bladder (when a problem in your brain, spinal cord, or central nervous system causes loss of bladder control). A review of Resident 2's Minimum Data Set ([MDS] a Federal mandated assessment tool), dated 7/18/2024, indicated Resident 2's cognition (thinking) was intact, she understood and could understand others. The MDS indicated Resident 2 required substantial maximum assistance rolling left to right, sitting to lying down, lying down to sitting and lying down to sitting on the side of the bed. A review of Resident 2's History and Physical (H&P), dated 9/6/2024, indicated Resident 2 had a fluctuating capacity to make decisions. A review of Resident 2's Progress Notes, dated 9/10/2024, indicated, at 9:25 p.m., CNA 1 attempted to put Resident 2 into bed several times because it was getting late but Resident 2 refused to go to bed. The Progress Notes indicated Resident 2 did not want CNA 1 to use a sling (a device that is attached to a mechanical lift [a device operated by a motor used to move a client from one position or place to another] used to move a patient from one surface to another) to assist with putting her in bed. The Progress Notes indicated when CNA 1 carried Resident 2 to the bed, Resident 2 suddenly bit CNA 1 on his arm, yelled, pulled on her indwelling urinary catheter (a thin hollow tube that is inserted into the bladder to drain urine), and struggled not to go to bed, which was when a skin tear was found on Resident 2's right wrist. During an interview on 9/24/2024, at 3:50 p.m., CNA 1 stated Resident 2 was usually transferred to bed via a mechanical lift, and she had a behavior of screaming. CNA 1 stated on 9/10/2024 around 10:30 p.m., Resident 2 was soiled, she did not want to go to bed, and she did not want the mechanical lift used to put her in bed. CNA 1 stated, he picked Resident 2 up from a Geri chair to put her into bed but acknowledged he could have left Resident 2 in the Geri chair she was sitting in, but his shift was almost over, and he did not want to leave Resident 2 wet and sitting in the Geri chair, which would have made Resident 2's family upset. During an interview on 9/24/2024, at 4:32 p.m., RNS 1 stated on 9/10/2024, after dinner, around 7 p.m., she told CNA 1 to put Resident 2 back to bed and Resident 2 yelled "No, I don't want to go to bed." RNS 1 stated she again asked Resident 2 to go to bed at 8 p.m., 9 p.m., and 10 p.m., but Resident 2 yelled and screamed because she did not want CNA 1 to use the mechanical lift to transfer her to the bed. RNS 1 stated CNA 1 stood in front of Resident 2, who was sitting in a Geri chair, and picked her up to place her into bed, that was when Resident 2 bit CNA 1 on his arm. RNS 1 stated, she observed Resident 2 with a skin tear on her right hand by the thumb, that measured approximately 2.0 cm long, and bled a little bit. RNS 1 stated they should have left Resident 2 in the Geri chair and called Resident 2's family member (FM 1), who could have spoken to Resident 2 to convince her to go to bed, or they could have come back later to try again and documented Resident 2's refusal of care in the resident's Progress Notes and care plan. During an observation and concurrent interview on 9/25/2024, at 10:50 a.m., at the GACH where Resident 2 was transferred on 9/20/2024 for an unrelated event, Resident 2 was observed with a purple discoloration on her right hand and mid right forearm. Resident 2 stated, on 9/10/2024 CNA 1 lifted her from the Geri chair she was sitting in to put her in bed even though she did not want to go to bed. Resident 2 stated she kept telling CNA 1 "No!! No!!" Resident 2 stated she wanted CNA 1 to use the mechanical lift to transfer her back to bed. Resident 2 stated, CNA 1 would not listen to her and kept coming towards her. Resident 2 stated, she yelled at him, saying she did not want to go to bed, and finally she just gave up. Resident 2 stated when CNA 1 lifted her from the Geri chair he squeezed her arms really hard. Resident 2 stated RNS 1 was there and told CNA 1 to put her (Resident 2) into bed. Resident 2 stated she felt no protection from RNS 1 and could see people in the hallway pass by as she yelled for help, and no one stopped to see if she was ok or ask CNA 1 what was he doing? Resident 2 stated this went on for about 20 to 30 minutes, she stated she was afraid of CNA 1, she no longer felt safe at the facility, and did not want to return there because it was the worst thing that ever happened to her. During an interview on 9/25/2024, at 3:34 p.m., the Director of Staff Development (DSD) stated if a resident refused to use a mechanical lift or refused any care, the CNAs (in general) were expected to stop, explain to the resident the reason care was needed and if the resident still refused, CNAs were instructed to report the refusal of care to the charge nurse, come back later and try again. The DSD stated the nurses could have called the family member to ask them to talk to the resident. During an interview on 9/25/2024, at 4:54 p.m., the Director of Nursing (DON) stated, on 9/10/2024 at around 9 a.m., she checked on Resident 2 and saw that Resident 2 had discoloration on both of her hands. The DON stated discoloration had always been there, but it seemed more pronounced than usual, she stated there was no swelling, or complaints of pain, and Resident 2 had full range of motion (the amount of movement a joint can make when its flexed, extended, and rotated) to both of her wrist and hands. The DON stated, there was a dressing around Resident 2's right wrist that was not there before the skin tear that Resident 2 sustained. The DON stated, she was told that Resident 2 did not want to go to bed, and she (Resident 2) did not want to be transferred without the mechanical lift, and staff should have let Resident 2 remain in her Geri chair, come back later, call Resident 2's family and/or Resident 2's physician if she (Resident 2) continued to refuse care. During a review of the facility's P&P, titled, "Activities of Daily Living (ADLs), Supporting," dated 3/2018, the P&P indicated, residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The P&P indicated the appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking). If a resident resist or refuses care, staff will attempt to identify the underlying cause of the behavior and consider approaching the resident in a different way or at a different time or having another staff member speak with the resident. The resident's response to interventions will be monitored, evaluated, and revised as appropriate. During a review of the facility's P&P, titled "Requesting, Refusing and/or Discontinuing Care or Treatment," dated 2/2021, the P&P indicated, residents and residents' representatives have the right to refuse and/or discontinue treatment. The resident is not forced to accept any care or treatment and may refuse or discontinue care or treatment at any time. This includes care or treatment prescribed by a physician, care or treatment that has been administered previously, and/or care or treatment that the resident previously agreed to but has not yet been administered. Documentation pertaining to a resident's request, discontinuation or refusal of treatment includes at least the following, the date and time the care or treatment was attempted, the type of care or treatment, the resident's response and stated reasons for request, discontinuation, or refusal, and that the resident is informed (to the extent of their ability to understand) of the purpose of the treatment and the potential outcome of not receiving the medication/ treatment. The facility failed to: 1. Ensure CNA 1 honored Resident 2's decision not to go back to bed and did not force her against her wishes back to bed by holding her arms tightly, which resulted in Resident 2 becoming combative as she resisted CNA 1's attempt to place her back in bed. 2. Ensure CNA 1 and RNS 1 followed the facility's P&P titled, "Activities of Daily Living (ADLs), Supporting," which indicated if a resident resist or refused care, staff would consider approaching the resident in a different way or at a different time or having another staff member speak with the resident. 3. Ensure CNA 1 and RNS 1 followed the facility's P&P titled, "Requesting, Refusing and/or Discontinuing Care or Treatment," which indicated residents have the right to refuse and/or discontinue treatment and was not forced to accept any care or treatment. These deficient practices resulted in Resident 2 becoming combative, when she was forced into bed against her wishes, while her arms were held tightly by CNA 1, causing bruises on her mid right forearm and right hand, and a skin tear on her right hand by the thumb, that measured approximately 2.0 cm long This violation had a direct relationship to the health, safety, or security of the Resident 2.