Other·June 30, 2023

42 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. (a) The facility must- (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 22 CCR § 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. The California Department of Public Health (CDPH) received a facility reported incident (FRI) on 4/24/2023 indicating a resident (Resident 1) alleged he was struck by a nurse (Licensed Vocational Nurse 1 [LVN 1]). The FRI indicated a witness observed LVN 1 tackle Resident 1 to the floor and strike him resulting in left eye lower lid discoloration. On 5/4/2023, CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Ensure Resident 1 was free from abuse when LVN 1 punched Resident 1 in the face. 2. Ensure LVN 1 treated Resident 1 with dignity and respect. As a result, Resident 1 developed a swollen and bruised left eye. A review of Resident 1’s Admission Record (Face Sheet), indicated the facility admitted Resident 1, a 53-year-old male, on 2/7/2023 with diagnoses including schizophrenia (serious mental disorder in which people interpret reality abnormally), anxiety disorder (feeling of worry or fear), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily living). A review of Resident 1’s “History and Physical” (H&P), dated 2/19/2023, indicated Resident 1 had the capacity to understand and make decisions intermittently related to acute psychosis (a clinical syndrome that involves hallucinations [perception of something not present], delusions [unable to tell what is real from what is imagined], disorganized thoughts or behaviors, or some combination within an acute timeframe often less than 1 month). A review of Resident 1’s Care Plan titled, “Behavior Problem” dated 2/19/23, indicated Resident 1 had auditory hallucinations and was socially inappropriate as evidenced by yelling, talking to self, and striking out at staff for no apparent reason. The interventions included to provide a non-confrontational environment for care, reinforce positive behavior and reduce stressors that may be contributing to the resident’s behavior. A review of Resident 1’s Minimum Data Set ([MDS] a standardized care screening and assessment tool), dated 2/26/2023, indicated Resident 1 had the capacity to understand and be understood intermittently. The MDS indicated Resident 1 had trouble concentrating, no physical behavioral symptoms directed toward others, and verbal behavioral symptoms directed toward others. The MDS indicated Resident 1 required supervision with activities of daily living ([ADL] activities related to personal care) when walking in corridor and toileting. A review of Resident 1’s Nurses Notes, dated 4/21/2023, indicated on 4/21/2023 at 3:00 a.m., Resident 1 was making loud noises in the hallway with Resident 4. LVN 1 intervened and separated the two residents (Resident 1 and Resident 4). Nurses Notes indicated on 4/21/2023 at 3:45 a.m., Resident 1 followed LVN 1 to the nurse station and started talking about shooting people and LVN 1 tried to calm Resident 1 down by asking him to go to his room then Resident 1 hit LVN 1 in the mouth. Staff escorted Resident 1 to his room without any incidents. A review of Resident 1’s Situation, Background, Assessment, and Recommendation (SBAR) form, dated 4/21/2023, indicated Resident 1 had a change of condition ([COC] a clinical deviation from a resident's baseline) with symptom, or sign observed and evaluated with a black eye (an area of bruised skin around the eye resulting from a blow). A review of Resident 1’s Interdisciplinary Care Plan, titled “Alteration in Skin Integrity,” dated 4/21/2023, indicated Resident 1 had left lower eyelid slight discoloration measuring 0.3 by ([x] proximity of measurement) 0.5 centimeters ([cm] unit of measurement). A review of Resident 1’s Care Plan titled, “Aggressive Behavior” dated 4/21/2023, after the incident indicated Resident 1 had an incident with staff, Resident 1 was anxious, restless and had delusional behavior (having false or unrealistic beliefs or opinions). The care plan indicated Resident 1 stated that he had a fight with someone where he was screaming, yelling, and should be shooting an unnamed resident. The care plan indicated Resident 1 stated he was fighting like animal, hit the unnamed person and someone wearing a green and black jacket hit him (Resident 1). A review of Certified Nursing Assistant 2’s (CNA 2) interview record (written statement) regarding the incident that happened on 4/21/2023, indicated he heard loud yelling coming from Nursing Station 1 and saw Resident 1 and LVN 1 were engaged in a verbal confrontation. CNA 2 indicated Resident 1 called LVN 1 a racial remark and hit LVN 1 in the mouth. CNA 2 put himself in between Resident 1 and LVN 1 to de-escalate the situation with his hands up and palms open to let Resident 1 know he was not trying to be the aggressor. Resident 1 took some steps back and focused on CNA 2, then LVN 1 ran from behind CNA 2 and tackled Resident 1 to the floor. CNA 2 stated while Resident 1 was on his back on the floor, LVN 1 put his knees on each one of Resident 1 arms to keep Resident 1 still on the floor and started to strike Resident 1 across his face. CNA 2 indicated the tackle was not needed because he (CNA 2) was already in between Resident 1 and LVN 1 to deescalate the situation. During an observation on 5/4/2023 at 11:00 a.m., Resident 1 was in hallway near his (Resident 1) room. Resident 1 was observed with swelling and bruising around his left eye. During a telephone interview on 5/4/2023 at 2:00 p.m., CNA 2 stated he witnessed Resident 1 and LVN 1 arguing and heard Resident 1 call LVN 1 a racial remark. CNA 2 stated Resident 1 was observed in a fighting posture and LVN 1 told Resident 1 “you are not going to do anything.” CNA 2 stated he saw Resident 1 hit LVN 1 in the mouth, then CNA 2 (with his hands up in a non-aggressive gesture) stood in between Resident 1 and LVN 1 to stop Resident 1 from hitting LVN 1 again. Resident 1 did not hit LVN 1 again. Resident 1 stepped away from LVN 1 then LVN 1 tackled Resident 1 to the ground and slapped Resident 1 in the face. CNA 2 stated Resident 1 fought back and tried to kick LVN 1 off him. CNA 2 stated LVN 1 should know that Resident 1 was a psychiatric (having mental illness) patient and should not hit Resident 1. During a telephone interview on 5/4/2023 at 3:00 p.m., LVN 1 stated, he was the charge nurse the night of 4/21/23 at 3:00 a.m. and was assigned to Resident 1. LVN 1 stated Resident 1 was fixated with Room A and LVN 1 asked Resident 1 to move away from the room. LVN 1 tried to make Resident 1 go to his room but instead of going back to his room, Resident 1 followed LVN 1 to the nursing station and yelled an inappropriate racial comment and hit LVN 1 in the mouth and neck. LVN 1 stated he tried to block the hits and moved away from Resident 1. LVN 1 stated Resident 1 stopped hitting him and walked back to his room. LVN 1 stated he should have “run for his life”, de-escalated (reduce the potential for violent situation), and redirected Resident 1. LVN 1 stated he never hit him (Resident 1). During an interview on 5/4/2023 at 3:40 p.m., the Director of Staff Development (DSD) stated she interviewed the staff and Resident 1. The DSD stated CNA 2 reported LVN 1 hit Resident 1 in the face. Resident 1 admitted hitting LVN 1 and stated LVN 1 punched him back. CNA 2 and Resident 1 statements were aligned about Resident 1 being hit by LVN 1. The DSD stated LVN 1 denied hitting Resident 1 and said he was hit by Resident 1. The DSD stated Resident 1 presented with discoloration of the left eye lid that morning and that Resident 1 should not have been hit by staff or anyone. The DSD stated LVN 1 resigned on 4/24/23. During an interview on 5/4/2023 at 3:55 p.m., with the Director of Nursing (DON) regarding the incident that happened on 4/21/2023, the DON stated LVN 1 reported Resident 1 had aggressive behavior and hit LVN 1 during the night shift. The DON stated during rounds on 4/21/12 at 6:00 a.m., she noticed Resident 1’s left eye was discolored. The DON stated she asked Resident 1 what happened, and Resident 1 said, he hit someone, and someone hit him back.” The DON stated, LVN 1 stated he does not know what happen to Resident 1’s eye. The DON stated CNA 2 was called by the DSD and was told Resident 1 hit LVN 1, and LVN 1 charged Resident 1 to the floor and punched Resident 1 in the face. The DON stated it was not okay for staff to hit residents. The DON stated it was important to give good customer service and the facility did not tolerate abusive behavior (a wide range of actions, words, and behaviors that are intended to control, manipulate, or harm another person). During an interview on 5/4/2023 at 4:15 p.m., the Administrator (ADM) stated that CNA 2 reported Resident 1 punched LVN 1 and LVN 1 hit Resident 1 in the face. The ADM stated the DON was doing rounds in the morning and noticed the discoloration to Resident 1’s left eye. The ADM stated CNA 2 reported LVN 1 hit Resident 1 in the face. Resident 1 was sent to the hospital on 4/21/2023. The ADM stated it was not okay to hit residents and the facility did not tolerate abusive behavior. During a concurrent interview and record review on 5/30/2023 at 3:15 p.m., with the DON, Resident 1’s Nurses Notes, dated 4/21/2023 were reviewed. Nurses Notes indicated Resident 1 stated he had a fight where he fought like an animal, he was screaming, yelling and should shout and shoot him (did not name who). Nurse’s notes indicated Resident 1 stated he hit them (did not indicate who) but “he” (did not specify name) hit him. The DON stated he asked Resident 1 who hit Resident 1, and Resident 1 stated he did not know, he was wearing a green uniform and black jacket. Nurse’s notes indicated at around 7 a.m., slight discoloration was noted on Resident 1’s lower left eye lid. The DON stated she was doing rounds that morning and noticed discoloration to Resident 1’s left eye. A review of the facility’s policy and procedure (P&P) titled, “Charge Nurse-RN/LVN Job Description,” undated, indicated, “The primary purpose of your job position was to provide direct nursing care to the residents and to supervise the day-to-day nursing activities performed by the certified nursing assistants. All care and supervision must be in accordance with current federal, state, and local standards, guidelines, regulations, and laws that govern our facility…Complies with abuse prevention & reporting policies and procedures.” A review of the facility’s P&P titled “Promoting/Maintaining Resident Dignity,” dated (2022), indicated, “It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident’s quality of life by recognizing each resident’s individuality.” A review of the facility’s P&P titled “Abuse, Neglect and Exploitation (the action or fact of treating someone unfairly in order to benefit from their work),” dated 2023, indicated, “Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals… Physical abuse includes, but is not limited to hitting, slapping, pinching, and kicking.” The facility failed to: 1. Ensure Resident 1 was free from abuse when LVN 1 punched Resident 1 in the face. 2. Ensure LVN 1 treated Resident 1 with dignity and respect. As a result, Resident 1 developed a swollen and bruised left eye. This violation presented either imminent danger that death or serious harm would result or a substantial probability