Health inspection·October 29, 2024

CFR § 483.12 - Freedom from abuse, neglect, and exploitation (c)In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (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. CCR § 72315(b) 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. CCR § 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. HSC § 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class “B” violation. On 9/17/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) was sexually abused by a male staff member of the facility. On 9/18/2024 CDPH conducted an unannounced visit to the facility to investigate the allegation. Upon investigation, CDPH determined there was another violation related to verbal abuse and not related to the complaint allegation. The facility failed to implement its abuse policy and procedure (P&P), titled, “Abuse Program Policy and Procedure” by not immediately reporting a resident-to-resident altercation to CDPH, and the State Long Term Care Ombudsman (an agency that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) within the regulated time frame of two hours Resident 2. This deficient practice resulted in CDPH’s inability to investigate the allegations of abuse timely and had the potential for other allegations of abuse to go unreported. a. A review of the Resident 1, a 56-year-old male’s, Admission Record indicated Resident 1 was admitted to the facility on 6/7/2024 with diagnoses including nontraumatic intracerebral hemorrhage (a stroke caused by a ruptured blood vessel), hemiplegia (severe muscle weakness) and hemiparesis (muscle weakness) following cerebrovascular disease (group of disorders that affect blood supply to the brain), abnormalities of gait and mobility, and hypertension (high blood pressure). A review of Resident 1’s Minimum Data Set [(MDS) a federally mandated resident assessment tool], dated 6/14/2024, indicated Resident 1 had intact cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) for daily decision making. The MDS indicated Resident 1 required maximal assistance in all aspects of activities of daily living (ADL) including bathing, transferring, personal hygiene, oral hygiene, except for eating which required supervision. The MDS indicated Resident 1 utilized a wheelchair and walker for mobility and had impairment on both the upper and lower extremities (arms and legs). The MDS indicated Resident 1 did not have any physical behavioral symptoms (hitting, kicking) or verbal behavioral symptoms (threatening others, screaming, or cursing at others). A review of Resident 2, a 68-year-old male’s, Admission Record indicated Resident 2 was admitted to the facility on 10/17/2021 with diagnoses including Wernicke’s encephalopathy (unusual type of memory disorder due to lack of vitamins that helps convert food into energy), difficulty walking, schizoaffective disorder (mental health condition that causes delusions (altered reality), hallucinations (hearing, seeing something that is not real), and mood disorders: depression, mania), and dementia (progressive loss of memory, thinking, and remembering) without behavioral disturbance (range of conditions such as agitation, distress). A review of Resident 2’s MDS dated 7/22/2024, indicated Resident 2’s cognitive skills were moderately impaired. The MDS indicated Resident 2 required moderate assistance in transferring from chair/bed to chair, walking, toilet/shower transfer and performing oral/toilet/personal hygiene. The MDS indicated Resident 2 utilized a wheelchair and walker for mobility and did not have any impairments on both the upper and lower extremities. A review of an untitled Care Plan (CP) initiated on 6/28/2024, indicated Resident 1 had an episode of verbally aggressive and threatening behavior. The CP interventions included to take resident away from triggering events and identify cause(s) such as if resident in pain or hungry and try to resolve/eliminate the cause. A review of the Medication Administration Record (MAR) indicated Resident 1 had an aggressive and threatening behavior on 6/30/2024 in the evening, threatening behavior on 7/10/2024 in the day and evening, and had verbally aggressive behaviors from 7/10/2024 to 7/17/2024 throughout each day. A review of a Change of Condition dated 8/20/2024, indicated Resident 1 had physically aggressive/striking behavior, attempting to strike another resident, and was verbally aggressive toward staff and other residents. A review of the Interdisciplinary Team ([IDT] group of individuals that specialize in various healthcare areas, that meet with the resident/family to discuss ways to promote optimal patient care outcomes) Conference notes dated 8/20/2024 at 2:09 p.m., indicated Resident 2’s family members (FM 2 and FM 3) expressed they were uncomfortable with Resident 1 (Resident 2’s roommate) as he had  been cursing at them when they visit Resident 2 but FM2 and FM3 stated they did not report it to anyone, they let it pass. During an interview on 9/22/2024 at 9:34 a.m., with FM 2 and FM 3, FM 2 stated on 8/20/2024, Resident 1 was in his wheelchair and blocked the door (the only entrance to the room) so Resident 2 could not enter the room from the hallway. FM 2 stated herself and FM3 were both in Resident 1 and Resident 2’s shared room and Resident 1 started yelling and cussing at Resident 2 and the staff. FM 2 stated they made a report to the facility as they were scared for Resident 2 because Resident 1 was making threatening remarks. FM 3 stated when she reported this to the nursing station, the staff informed her they could not make Resident 1 change rooms and they did not want to move Resident 2 out of that room since he had been there for several years and was very familiar with where everything was. A review of the facility’s Incident Investigation Summary Reports indicated there was no Investigation Summary Report for the incident of verbal abuse by Resident 1 toward Resident 2 on 8/20/2024. During an interview on 9/18/2024 at 1:52 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she and CNA 1 witnessed the incident of abuse by Resident 1 to Resident 2 on 8/20/2024 around 2:00 p.m. LVN 1 stated Resident 1 was suddenly screaming and trying to hit Resident 2. LVN 1 stated she intervened before Resident 1 hit Resident 2. LVN 1 stated she notified the doctor, the Administrator (ADM), the Director of Nursing (DON), and the Registered Nurse Supervisor 1 (RNS 1). LVN 1 stated Resident 1 was sent out to the hospital on 8/20/2024. LVN 1 stated getting yelled at, cussed at, and threatened is considered harassment and verbally abusive. LVN 1 stated this incident was s a case of verbal abuse and should have been reported to the authorities. LVN 1 stated it should have been reported so the incident would have been investigated, and the residents would have been monitored for possible harm. During an interview and review of the IDT meeting notes dated 8/20/2024 with the ADM on 9/18/2024 at 4:37 p.m., the ADM stated when there is a resident-to-resident verbal or physical altercation, we must investigate the incident, speak to the residents, the individual who reported it, witnesses, and report it to the CDPH, Ombudsman, and the police. The ADM stated there were different types of abuse which included financial, physical, and verbal abuse. The ADM stated FM 3 indicated she was scared Resident 1 would hurt Resident 2. The ADM stated Resident 1 had aggressive behaviors towards Resident 2 and that was considered abuse. During a review of the facility’s P&P, titled, “Abuse Program Policy and Procedure” revised on 6/20/2024, the P&P indicated the facility shall uphold resident’s right to be free from verbal, sexual, physical, mental abuse, corporal punishment, and involuntary seclusion. “Verbal Abuse” is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again. Facility shall also institute procedures that allows for identification, correction, and intervention in situations in which abuse, neglect and/or misappropriate of resident property is more likely to occur…areas of identification, correction and intervention may include but not limited to, facility environment, staffing and supervision of staff, identification of residents with potential for behavioral symptoms and manifestations that may lead to conflict or anger through comprehensive assessment, care planning, and monitoring. Any incidence or occurrences that may constitute abuse shall be recorded on the Incident Report Form and reported to Director of Nurses, Facility Administrator…immediately after and/or no later than 24 hours after the identification of the unusual occurrence or events constituting abuse or probably abuse. Facility Administrator shall be responsible for reporting of all alleged and substantiated violations to the state agency and all other agencies as required. Facility shall report the incident by calling the DHS within 24 hours of the knowledge of such incident; followed by a letter explaining the circumstances surrounding the incident. Facility Administrator shall be responsible for overall implementation of corrective measures and plan of action; including but not limited to determining necessary systemic changes…to prevent further occurrences of said violations. During a review of the facility’s P&P, titled, “Resident Rights," undated, indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights including the resident's right to be free from abuse.  The facility failed to implement its abuse policy and procedure (P&P), titled, “Abuse Program Policy and Procedure” by not immediately reporting a resident-to-resident altercation to CDPH, and the State Long Term Care Ombudsman (an agency that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) within the regulated time frame of two hours Resident 2. This deficient practice resulted in CDPH’s inability to investigate the allegations of abuse timely and had the potential for other allegations of abuse to go unreported. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 2.