Other·April 11, 2024

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation. §483.12 (b) 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. (b) The facility must develop and implement written policies and procedures. CFR §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 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. §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. 22CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. 22 CCR § 72527 Patient’s 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. §72311. Nursing Service - General. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The California Department of Public Health (CDPH) received an entity reported incident (ERI) on 3/14/2024, indicating Resident 1 was hit by Resident 2. On 3/15/2024, at 11:23 a.m., CDPH conducted an unannounced investigation at the facility. The facility failed to: 1. Ensure Resident 1 was monitored for wandering (moving from place to place without a fixed plan or purpose) throughout the facility. Resident 1 wandered into Resident 2’s room and Resident 2 hitting Resident 1 on the right eye.     2. Ensure staff followed Resident 1's Care Plan titled "Resident is an elopement risk/wanderer related to dementia (a decline in memory, language, problem-solving and other thinking skills that affect one’s ability to perform everyday activities)" with intervention a sitter (a person who sits) for constant monitoring for safety purposes.     3. Ensure staff implemented Resident 1's care plan titled "Risk for harm: Other-directed behavior potentially causing harm with interventions indicating if wandering or pacing, staff should initiate visual supervision, reorient the resident and monitor factors that may contribute to violent behaviors.     4. Follow its policy and procedure (P&P), titled, "Abuse-Prevention, Screening, and Training Program," dated 7/2018, which indicated facility did not condone any form of resident abuse or neglect.  As a result, Resident 1, sustained a hematoma (broken blood vessels) under the right eye, that required hospitalization in an acute care hospital (GACH) for evaluation and treatment. Findings: a. Resident 1 was a 70-year-old female, admitted to the facility on 8/1/2023 and readmitted on 3/7/2024. Resident 1's diagnosis included schizoaffective disorder (a mental illness that affects person’s thoughts, mood, and behavior), Type 2 diabetes mellitus ([DM] abnormal blood sugar), and dementia.  A review of Resident 1's History and Physical (H&P), dated 2/18/2024, indicated, Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] an assessment and care screening tool), dated 2/18/2024, indicated, Resident 1 had wandering behaviors. The MDS indicated, Resident 1 required partial or moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene and upper body dressing (the ability to dress and undress above the waist), and lower body dressing (the ability to dress and undress below the waist).  A review of Resident 1’s care plan titled "Risk for harm: Other-directed behavior potentially causing harm,” dated 12/20/2023, indicated Resident 1 entered other residents’ rooms rummaged (searching and moving) through their personal belongings and was at risk for harm. The care plan interventions indicated if Resident 1 was wandering or pacing, staff would initiate visual supervision, and reorient the resident. The interventions also indicated staff will monitor Resident 1 for cognitive, emotional, or environmental factors that may contribute to violent behaviors.  A review of Resident 1's Care Plan titled "Resident is an elopement risk/wanderer related to dementia” dated 12/20/2023, indicated staff will distract Resident 1 from wandering by offering pleasant diversions such as food, conversations, and structured activities. The intervention indicated staff will identify what triggered Resident 1 to wander, if there was a pattern of wandering, if Resident 1 wandering was aimless, or if the resident was looking for something or needed an exercise and then staff will intervene appropriately. The intervention also indicated staff will place Resident 1 closer to the nurses’ station for constant monitoring, reorient and offer her something she enjoyed doing in the activities room.    A review of Resident 1's Psychiatric Evaluation, dated 2/21/2024, indicated Resident 2 had an assigned sitter due to confused behavior, restlessness, agitation and unable to follow commands.  A review of Resident 1's Situation, Background, Assessment, and Recommendation form ([SBAR] a communication tool used to communicate a resident’s change of condition), dated 3/13/2024, at 6:30 p.m., indicated a Certified Nursing Assistant (CNA) 1 observed Resident 1 lying on Resident 2’s bed and Resident 2 sitting on a wheelchair. The SBAR indicated CNA 1 observed Resident 2, hitting Resident 1 on the right eye with a wooden back scratcher. The SBAR also indicated Resident 1 sustained a hematoma on the right eye.  A review of Resident 1's Wound Assessment, dated 3/13/2024, indicated Resident 2 had hematoma on the right periorbital area (around the eye). The Wound Assessment also indicated staff will cleanse Resident 1’s hematoma with normal saline, pat dry, leave open to air and apply cold compress thereafter.  A review of Resident 1's Emergency Room (ER) report, dated 3/13/2024, indicated Resident 1 had a diagnosis of assault, and periorbital ecchymosis (bruising and discoloration) around the right eye.  Resident 1’s Computed Tomography scan ([CT] process of taking pictures of body parts to diagnose and treat disease or injury) of the face, indicated Resident 1 had right periorbital soft tissue swelling. On 3/15/2024 at 11:41 a.m., during a concurrent observation and interview with Resident 1, Resident 1 was observed with a purplish and bluish skin discoloration around her right eye. Resident 1 was alert and oriented to her name only. Resident 1 stated, she rolled off the couch then landed on the ground.  On 3/15/2024 at 12:38 p.m., during a phone with LVN 2, LVN 2 stated Resident 1 had a sitter assigned to her on 3/13/2024, no sitter was assigned Resident 1, during the night shift. LVN 2 stated she did not know why Resident 1 did not have a sitter that evening. LVN 2 stated when Resident 2 hit Resident 1, no staff was monitoring Resident 1. LVN 2 stated the incident could had been avoided if the facility had assigned a sitter to monitor the resident’s whereabouts because the resident wandered into other residents’ rooms.  On 3/15/2024 at 1:12 p.m., during an interview with LVN 1, LVN 1 stated the incident between Resident 1 and Resident 2 happened on 3/13/2024 at 6:30 p.m. LVN 1 stated CNA 1 witnessed the incident. LVN 1 stated that evening, no sitter was assigned to follow, monitor, and redirect Resident 1’s wandering behaviors. LVN 2 stated Resident 2 had an anxiety (feelings of fear and uneasiness) behavior and easily get agitated. LVN 2 stated there were a sitter provided to Resident 2 on 3/13/2024 day shift but not on evening shift.  On 3/15/2024 at 3:21 p.m., during an interview with CNA 1, CNA 1 stated she witnessed the incident between Resident 1 and 2. CNA 1 stated she was in another resident’s room, when she heard a voice coming from Resident 2 's room.  CNA 1 stated she immediately responded by going into Resident 2’s room.  CNA 1 stated she observed Resident 2 sitting on his wheelchair inside and Resident 1 was lying on Resident 2's bed, yelling for help. CNA 1 stated she observed Resident 2 hitting Resident 1 on the right side of her face with a wooden back scratcher. CNA 1 stated she observed Resident 1 with a big bruise around her right eye with slight bleeding on her right side of the face.   On 3/15/2024 at 3:45 p.m., during an interview with the Administrator (ADM), the ADM stated he was informed Resident 2 struck Resident 1 with a wooden back scratcher. The ADM stated Resident 1 sustained a big bruise on her right eye and it was considered a major bodily injury. The ADM stated staff should have redirected Resident 1 before she went to Resident 2 ' s room. The ADM stated the facility failed to keep track of Resident 1’s whereabouts, to prevent her from going to Resident 2 ' s room. The ADM stated it was unfortunate because Resident 1 was physically abused by Resident 2.  On 3/18/2024 at 10:17 a.m., during an interview with CNA 2, CNA 2 stated she was assigned to Resident 1 on 3/13/2024 for the evening shift. CNA 2 stated she was busy passing dinner trays to other residents when the incident occurred. CNA 2 stated Resident 1 had a behavior of screaming and yelling. CNA 2 stated it was not easy redirecting Resident 2 and usually required 2 staff to talk to the resident. CNA 2 stated she had seen Resident 1 in the past going to Resident 2 ' s room but Resident 1 had a sitter that followed her around.  On 3/18/2024 at 10:57 a.m., during a concurrent interview and record review with the Minimum Data Set Nurse (MDS Nurse), the Resident 1’s care plan titled "The resident is an elopement risk/wanderer related to dementia" dated 12/20/2023, and "Risk for harm-directed behavior potentially causing harm, she enters other resident ' s rooms and rummages through their belongings” dated 12/20/2023, were reviewed. The MDS Nurse stated the care plan goal for safety to be maintained were not met by the facility. The MDS Nurse stated visual monitoring meant Resident 1 was supposed to be monitored every hour. The MDS Nurse stated Resident 1 was not monitored every hour.  On 3/18/2024 at 11:20 a.m., during a concurrent interview and record review with the Director of Nursing (DON), the daily staff assignment sheet from 3/1/2024 to 3/14/2024 were reviewed. The DON stated the facility did not assign a sitter to Resident 1 on the following days:    3/1/2024, 7-3 shift, 3-11 shift, 11-7 shift.  3/2/2024, 3-11 shift and 11-7 shift.  3/3/2024, 3-11 shift and 11-7 shift.  3/4/2024, 3-11 shift and 11-7 shift.  3/5/2024, 3-11 shift and 11-7 shift.  3/6/2024, 7-3 shift, 3-11 shift, 11-7 shift.  3/7/2024, 7-3 shift, 3-11 shift, 11-7 shift.  3/8/2024, 3-11 shift and 11-7 shift.  3/9/2024, 7-3 shift, 3-11 shift, 11-7 shift.  3/10/2024, 11-7 shift.  3/11/2024, 3-11 shift and 11-7 shift.  3/12/2024, 3-11 shift and 11-7 shift.  3/13/2024, 3-11 shift.  3/14/2024, 7-3 shift and 11-7 shift.  The DON stated a sitter was not assigned to Resident 1 because there was no physician’s order, and therefore no visual monitoring was done.   On 3/18/2024 at 1:50 p.m., during an interview with the ADM, the ADM stated there were lapses within the period when Resident 1 entered Resident 2 ' s room. The ADM stated Resident 1 was not supervised when she was attacked by Resident 2.  The ADM stated since Resident 1 sustained an injury, the facility did not prevent Resident 1 from physical abuse by Resident 2.   b. Resident 2 was a 70-year-old male admitted to the facility on 10/27/2020 and readmitted on 1/9/2024.  Resident 2’s diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person ' s mood, energy, activity levels, and concentration), depression (feeling of sadness and loss of interest in daily activities).  A review of Resident 2's H&P, dated 1/11/2024, indicated, Resident 2 had the capacity to understand and make decisions.  A review of Resident 2's MDS dated 3/4/2024, indicated, Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene and toileting hygiene.    A review of Resident 2’s care plan titled “Risk for harm: self-directed or other directed,” dated 1/10/2024, indicated Resident 2 will not harm himself or others and will be free of physically aggressive behavior. The care plan intervention indicated staff will monitor Resident 2 for signs and symptoms of agitation.     A review of Resident 2’s care plan titled “Resident has potential to be verbally aggressive and uncontrollable angry outburst related to agitation and poor impulse control,” dated 1/10/2024, indicated staff will intervene before Resident 2’s agitation escalated.     A review of Resident 2’s Psychiatric Evaluation, dated 2/20/2024, indicated Resident 2 had mood swings (sudden change in how one feels), verbal aggression towards staff, other patients and the resident was easily irritable.   On 3/15/2024 at 2:10 p.m., during an interview with the DON, the DON stated the facility assigned a sitter to Resident 1 only when there was an extra nurse. The DON stated a sitter was responsible for monitoring residents to prevent accidents, and to redirect residents' behavior from wandering into other residents’ rooms. The DON stated interventions for wandering residents included redirection of behavior, 1:1 monitoring (staff immediately at hand and help prevent a fall or redirect a resident from engaging in a harmful act), and frequent visual checks. The DON stated frequent visual checks, staff had to check the resident at least every hour. The DON stated the facility did not provide visual monitoring for Resident 1.  The DON stated when a resident was on 1:1 monitoring, the staff was supposed to always be with the resident, observe, and redirect resident. The DON stated Resident 1 required constant monitoring, all the time (24 hours, 7 days a week). The DON stated there were no visual monitoring logs of Resident 1 ' s whereabouts. The DON also stated the facility did not condone any form of resident abuse and residents had the right to be free from abuse.   On 3/15/2024 at 2:45 p.m., during an interview with the Director of Staff Development (DSD), DSD stated she was responsible for assigning a sitter for Resident 1. DSD stated a sitter was provided to Resident 1 on 3/13/2024 during the day shift but none during the evening shift because there were no staff available to