Other·August 19, 2022

F600 §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. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.

F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(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. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 22 CCR 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. 22 CCR 72527. Patients' 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: (9) To be free from mental and physical abuse. On 06/25/2022, the Department of Public Health (State Survey Agency [SSA]) made an unannounced visit to the facility to investigate a complaint related to resident abuse. The facility failed to: 1. Ensure Resident 1 was free from physical abuse. 2. Report to the SSA, the local Long-Term Care Ombudsman (assist residents in the long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), and local law enforcement about the physical altercation between two residents, (Residents 1 and 2) not later than 2 hours after the incident. As a result, Resident 1 experiencing a fall and head injury and there was a delay in the SSA investigation and specifics of the alleged incident that occurred on 6/11/2022 at approximately 10:30pm between Residents 1 and 2 could not be obtained placing Resident 1 at risk for further abuse. A review of Resident 1's Admission Record indicated the facility admitted the resident, a 93-year-old female, on 2/28/20, with a medical history of high blood pressure and diabetes (High sugar level in the blood). A review of Resident 2's Admission Record indicated the facility admitted the resident, a 93-year-old female, on 4/3/2022 with diagnoses including a history of high blood pressure, Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 6/3/22, indicated the cognition of R 1 was impaired. A review of Resident 2’s MDS, dated 6/3/22, indicates the cognition of Resident 2 was severely impaired. A review of Resident 1’s Interdisciplinary Team (IDT, of professionals plan, coordinate and deliver you personalized health care) Incident Review, dated 6/11/22, indicated, "…around 10:30 pm while sitting in nursing station heard that resident is calling for help. Supervisor went to assess the resident and noted resident is on the floor and her roommate is on the top of [Resident 1] and is hitting her with a reacher grabber and [Resident 1] is pulling [Resident 2]’s hair. [Resident 1] explained to the supervisor that she was sitting on her wheelchair and her Roommate came towards her and tried to pull her out of wheelchair. Noted [Resident 1]’s head in a position that was hit by closet handle and caused a cut, bleeding and a big bump on the back of her head… Patient sent to ER [Emergency Room] for evaluation..." A review of Resident 2’s IDT - Incident Review, dated 6/11/22, indicated, "Supervisor at around 10:30 pm while sitting in nursing station heard that resident is calling for help. Supervisor went to assess the resident and noted resident is on the floor and her roommate is on the top of [Resident 1] and is hitting her with a reacher grabber and [Resident 1] is pulling [Resident 2]’s hair. [Resident 1] explained to the supervisor that she was sitting on her wheelchair and her Roommate came towards her and tried to pull her out of wheelchair. Noted [Resident 1] head in a position that was hit by closet handle and Care Hospital (GACH)…” A review of Resident 1’s Change in Condition Note, dated 6/11/22, indicated, "pt transferred to hospital, for cut on head." A review of Resident 1’s Skilled Charting, dated 6/10/22, indicated, "pt alert. reports headache. hospitalized due to physical fight." A review of Resident 1’s Change in Condition, dated 6/13/22, indicated, "Note Text: Pt. c/o nausea and headache. Will transfer to ER for further evaluation." During an interview on 6/27/22, at 3:12 PM, Administrator (ADM) 1 stated the facility did not report the physical altercation between Residents 1 and 2 as a possible resident abuse. A review of a letter written by the Administrator, addressed to the SSA, dated 6/28/22, indicated, "Regarding the non-report: It was not viewed as abuse due to Resident 2’s diagnosis of dementia/Alzheimer’s, there was absolutely no abuse that took place. Resident 2 isn't even aware of her surroundings…” During an interview with Ombudsman (OMB) 1, on 6/28/22 at 2:42 PM, the OMB 1 stated the facility did not report a physical altercation resulting in an injury between Residents 1 and 2 in the month of June of 2022 by phone, fax, email, or in person. A review of the facility’s policy and procedures titled “Abuse and Neglect - Clinical Protocol,” dated 3/2016, indicated, “The management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations." The facility failed to: 1. Ensure Resident 1 was free from physical abuse. 2. Report to the SSA, the local Long-Term Care Ombudsman and local law enforcement about the physical altercation between two residents, (Residents 1 and 2) not later than 2 hours after the incident. As a result, Resident 1 experiencing a fall and head injury and there was a delay in the SSA investigation and specifics of the alleged incident that occurred on 6/11/2022 at approximately 10:30pm between Residents 1 and 2 could not be obtained placing Resident 1 at risk for further abuse. The above violation had a direct relationship to the health, safety, and security of Resident 1.