Health inspection·July 18, 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 § 72311 - Nursing Service – General (a) Nursing service shall include, but not be limited to, the following:(1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 10/24/22 the California Department of Public Health (CDPH) received a complaint indicating a Certified Nursing Assistant (CNA 1) grabbed and pulled Resident 1’s right hand and bent the resident’s fourth and fifth fingers during a shower. Resident 1 alleged CNA 1 pushed her fingers backward. On 10/27/2022, the CDPH conducted an unannounced visit at the facility to investigate the complaint allegation. The facility failed to: 1. Ensure Resident 1 was not subjected to physical abuse from CNA 1 who showered Resident 1 with “very hot water” and grabbed Resident 1’s right hand and bent the resident’s fingers backwards. 2. Follow the facility’s policy and procedure (P/P), titled “Abuse Prohibition and Prevention Program,” when CNA 1 physically abused Resident 1. These violations resulted in Resident 1 sustaining an acute fracture (broken bone) to the right fifth finger (pinky finger), that required transfer to a general acute care hospital (GACH) and splinting. Resident 1 was a 75-year-old female admitted to the facility on 4/22/2021, with diagnoses including muscle weakness and multiple fractures of the ribs. A review of Resident 1’s History and Physical (H/P), dated 4/7/2022, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/26/22, indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required a one-person assist for bed mobility, locomotion (moving from one place to another), dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 required a two-person assist for transfers. A review of Resident 1’s X-ray report (a photographic or digital image of body tissues, organs, and structures inside the body) dated 10/24/2022, indicated Resident 1 had an acute fracture of the right fifth proximal (situated nearer the center of the body or the point of attachment) phalanx (the bones that make up the fingers of the hand and the toes of the foot) of fifth finger. On 10/24/2022 Resident 1 was transferred to the GACH for evaluation of right-hand pain. A review of Resident 1’s GACH Emergency Department (ED) Physician’s notes dated 10/24/2022, at 10:43 p.m., indicated Resident 1 was admitted to the ED on 10/24/2022 complaining of pain to the right hand, elbow and bilateral (both) shoulders which began two days after CNA 1 pulled Resident 1’s arm during a shower. The ED notes indicated that according to Resident 1’s X-ray dated 10/24/2022, Resident 1 had an acute fracture of the right fifth proximal phalanx. The ED notes indicated Resident 1 complained of pain to the right hand, right elbow, and right shoulder. The notes indicated the ED splinted the affected finger and discharged Resident 1 back to the facility on 10/24/2022. During a concurrent observation and interview on 10/27/2022 at 11:40 a.m., Resident 1 was noted with a purple and green discoloration at the base of the first knuckle of fifth and fourth fingers. Resident 1 was observed with discoloration on the palm of the right hand. Resident 1 stated on 10/22/2022, CNA 1 took her to the shower and did not talk to her at all. Resident 1 stated CNA 1 opened the hand-held shower head, sprayed very hot water on her (Resident 1) and CNA 1 started to wash the resident. Resident 1 stated “I told my nurse the water was very hot, and that she was burning me.” Resident 1 stated CNA 1 continued to spray the very hot water from Resident 1’s feet moving towards her upper body and as the water was reaching Resident 1’s face, Resident 1 raised her hands to protect her face from the hot water. Resident 1 stated CNA 1 threw the shower head on the floor and grabbed Resident 1’s fingers with her hand placing her weight onto the resident’s right hand bending her fingers backward. Resident 1 stated she told CNA 1 that she was breaking her hand, but CNA 1 kept pushing the resident’s fingers with all her weight. Resident 1 stated she kept yelling at CNA 1 to stop but CNA 1 would not stop, until Resident 1 tried to reach out with her left hand and attempted to pull CNA 1’s hair. Resident 1 stated her right hand hurt so bad and she reported the entire incident to CNA 2 and Licensed Vocational Nurse (LVN) 1 during night shift. During an interview with LVN 1 on 10/27/2022 at 12:45 p.m., LVN 1 stated on 10/22/2022, she worked on the 3:00 p.m. to 11:00 p.m. shift. On 10/22/2022 at 10:45 p.m., Resident 1 reported that she had swelling, pain and discoloration to her right hand. LVN 1 stated she observed Resident 1’s right lower hand swollen, bluish-purple in color and when she touched the area Resident 1 complained of pain. LVN 1 stated Resident 1 informed her CNA 1 hurt the resident’s right hand, in the shower. LVN 1 stated she did a change of condition and notified the resident’s physician (MD). During an interview with Family Member (FM) 1 on 10/27/2022 at 2:00 p.m., FM 1 stated she received a call from Resident 1 on 10/22/2022 at midnight and Resident 1 reported that CNA 1 sprayed very hot water on her in the shower and when Resident 1 tried to protect herself, CNA 1 grabbed the resident’s hand and pushed Resident 1’s fingers backward. FM 1 stated Resident 1 told her Resident 1 was in a lot of pain and believed CNA 1 was mad at Resident 1 because the resident had previously complained about being left wet by CNA 1. FM 1 stated when she spoke with LVN 4, LVN 4 stated Resident 1 had hit herself. FM 1 saw Resident 1’s bruised right fingers and told LVN 4 that it did not look like Resident 1 had hit herself. FM 1 stated she believed Resident 1’s statement of being hurt by CNA 1 and requested an x-ray of the resident’s fingers. During an interview with CNA 2 on 10/28/2022 at 2:50 p.m., CNA 2 stated on 10/22/2022 at 10:30 p.m., Resident 1 reported that CNA 1 had hurt her in the shower. CNA 2 stated she observed Resident 1’s right hand was purple. Resident 1 reported she was arguing with CNA 1 about the water being hot. CNA 2 stated that Resident 1 told her that CNA 1 threw the head of the shower on the floor then walked towards her and grabbed the fingers of her right hand. CNA 1 pushed Resident 1’s fingers back and her (Resident 1) fingers hurt so much. The following day, on 10/23/2022, she (CNA 2) was asked to translate for Resident 1. Through translation, Resident 1 reported that she had asked if CNA 1 was “stupid” because she was burning her with hot water and CNA 1 only stopped bending Resident 1’s fingers when Resident 1 reached for the CNA’s hair and pulled it. CNA 2 stated Resident 1 was very sensitive and did not like hot water. A review of the facility’s Final Summary report dated 10/28/2022, indicated Resident 1 was alert and oriented to the facility staff and was able to make her needs known. The report indicated the facility supported evidence through the resident’s reported statement that the quality of care, lack of professionalism and discourtesy occurred at the time of Resident 1’s shower by CNA 1. The report indicated Resident 1 was mishandled during care. A review of the facility’s P/P titled “Abuse Prohibition and Prevention Program,” dated November 2017, indicated the facility had “policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of resident property.” The P/P indicated the facility “strives to provide an environment which prohibits and prevents abuse, neglect, and exploitation of residents and misappropriation of resident property… will provide protection of residents from harm during an investigation.” A review of the facility’s P/P titled “Reporting of Alleged Violations Physical Abuse” dated November 2020, indicated “the facility prohibits the use of verbal, mental, sexual, physical abuse, neglect, misappropriation of resident property, exploitation, and/or involuntary seclusion, and physical or chemical restraint not required to treat the resident's symptom(s).” The P/P defined abuse as “the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish." The P/P indicated the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing was considered abuse.” According to the P/P, physical abuse included hitting, slapping, punching, kicking, and controlling behavior through corporal punishment. The facility failed to: 1. Ensure Resident 1 was not subjected to physical abuse from CNA 1 who showered Resident 1 with “very hot water” and grabbed Resident 1’s right hand and bent the resident’s fingers backwards. 2. Follow the facility’s P/P, titled “Abuse Prohibition and Prevention Program,” when CNA 1 physically abused Resident 1. These violations resulted in Resident 1 sustaining an acute fracture (broken bone) to the right fifth finger, that required transfer to a GACH and splinting. The above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result to Resident 1.