Health inspection·July 24, 2024

42 CFR §483.12: Freedom from Abuse, Neglect, and Exploitation §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. 42 CFR §483.12(b): Freedom from Abuse, Neglect, and Exploitation §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under 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. On 6/18/2024, CDPH conducted onsite investigation at the facility regarding resident-to-resident abuse. The facility failed to protect Resident 1 from verbal abuse (the use of oral, written, or gestured communication, or sounds, to residents; including harassing, mocking, yelling, cussing, or threatening) by failing to ensure Licensed Vocational Nurse 2 (LVN2) did not engage in a verbal altercation with Resident 1 and cuss at Resident 1. As a result, Resident 1 was exposed to verbal abuse from LVN2, placing the Resident 1 at risk for psychosocial harm, mental anguish (suffering) and emotional distress. A review of Resident 1's admission record indicated the facility admitted the 74-year-old male on 5/16/2024, with diagnoses that included encephalopathy (a disorder of the brain caused by disease, injury, drugs, or chemicals), psychosis (a mental disorder in which a person loses the ability to recognize reality or relate to others), depression and anxiety disorder. A review of Resident 1's Minimum Data Set (MDS- standardized data collection tool used to assess cognitive brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions] and functional status, and care needs) dated 5/16/2024, indicated Resident 1 had moderate cognitive (ability to think, read, learn, remember, reason, express thoughts, and make decisions) impairment. A review of Resident 1's situation background assessment and recommendation (SBAR: a form that is a documentation of a complete assessment in response to a change in condition) form dated 5/22/2024 at 6:10 pm, indicated Resident 1 had a verbal altercation with a staff member (LVN2). The SBAR form indicated Resident 1 was placed on 72-hour monitoring. A review of a facility document titled "Corrective Action Memo" dated 5/29/2024, indicated "On 5/22/2024 the employee (LVN2) stated that on 5/16/2024 she (LVN2) cursed at a resident (Resident 1) in violation of the facility's abuse preventions policy and procedure, facility code of conduct, and nursing code of conduct". A review of a facility document titled "Termination of Employment/Exit Interview" dated 5/29/2024, indicated LVN2's employment with the facility was terminated effective 5/29/2024, with a last date of work of 5/22/2024. The document indicated the reason for termination was "Employee violated abuse policy and procedures". During an interview on 6/11/2024 at 10:25am, Resident 1 denied experiencing verbal abuse from the facility staff stating, "I don't remember." During an interview on 6/11/2024 at 12:10 pm, Administrator (ADM) stated on 5/22/2024 during a 1:1 (one to one) education on ways de-escalating and re-directing a resident in crisis prompted by LVN2s history of unnecessary emergency calls to 911. ADM stated LVN 2 "made a huge stink" about Resident 1 psychological distress and admitted during the meeting that she (LVN2) told Resident1 "fuck you (FU)". ADM further stated "that's how to handle stuff and it works. During a telephone interview on 6/13/2024 at 10:45 am LVN2 stated on 5/16/2024 while getting ready to pass medications, LVN2 observed Resident 1 grabbing the receptionist's computer keyboard and a condensed aerosol spray that were on the receptionist desk then proceeded to bang the computer keyboard on the reception desk. Resident 1 seemed enraged without provocation. Resident 1 swung the computer keyboard and attempted to spray any staff who tried to calm him down or approach him. LVN2 stated she called 911 as Resident 1's aggression escalated because she was concerned about the safety of the other residents and staff in the facility. LVN2 denied verbally abusing Resident 1. A review of LVN2's employee file indicated LVN2 a current license, had no previous disciplinary actions. A facility background check dated 6/11/2024 indicated there were no concerns on LVN2 license record and, facility records indicated LVN2 was provided with initial abuse and code of conduct training on 2/14/2023. A review of the facility's policy and procedures (P&P) titled "Abuse Prevention" dated, revised 12/2018, indicated, "facility does not condone any form of Resident abuse ... including verbal abuse ... Verbal abuse is defined as any use of oral, written, gestured communication or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing distance regardless of age, ability to comprehend or disability." A review of the facility P&P titled "Code and Behavior" dated, revised 5/2019, indicated, "conduct that interferes with the care of residents ......any act that is offensive to a resident ... will not be condoned and may be grounds for disciplinary action. Examples conduct, and behavior considered inappropriate and therefor prohibited by this policy include but are not limited to: ...using profanity, abusive or suggestive language or gestures." The facility failed to protect Resident 1 from verbal abuse by failing to ensure LVN2 did not engage in a verbal altercation with Resident 1 and cuss at Resident 1. As a result, Resident 1 was exposed to verbal abuse from LVN2, placing the Resident 1 at risk for psychosocial harm, mental anguish, and emotional distress. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.