Health inspection·April 19, 2024

§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; 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: (10) To be free from mental and physical abuse. On 3/6/2024, an unannounced visit was made to the facility to conduct the facility reported incident regarding abuse. The facility failed to protect the resident’s right and ensure Resident 1, who had diagnoses including encephalopathy (a change in the way your brain works or a change in your body that affects your brain), was provided protection and free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) from Family Member 1. Resident 1, reported to the facility staff and police that Family Member 1 slapped her in the face on 2/26/2024. As a result, on 2/27/2024 (the next day), Family Member 1 returned to the facility, was found inside Resident 1's room, and slapped Resident 1 a second time. This placed Resident 1 at further risk of physical abuse from Family Member 1. A review of the admission record dated 8/7/2023, indicated Resident 1 was admitted to the facility with diagnoses including encephalopathy, essential hypertension (abnormally high blood pressure, not the result of a medical condition), chronic pain syndrome (causes pain and other symptoms in certain parts of your body, usually in your extremities). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 2/6/2024, indicated Resident 1 had no evidence of acute change in mental status. According to a review of the facility's Change in Condition (COC) document, dated 2/26/2024, indicated Resident 1 reported to the police that Family Member 1 slapped her on the left side of her cheek and the facility conducted an investigation report. A review of the facility's COC document, dated 2/27/2024, indicated Resident 1's Family Member had open handed contact with Resident 1's left face. The facility investigation report indicated that on 2/27/2024, Family Member 1 was inside Resident 1's room and made open hand contact with the resident's left side of the face. During an interview on 3/6/2024 at 12 PM, Resident 1 stated, "This was made into more than what it was. I was hit on the left side of the cheek, but it got blown out of proportion." During an interview on 3/6/2024 at 2:30 PM, Licensed Vocational Nurse 1 stated, “We were having issues with Family Member 1.” He would accuse staff of giving the resident the wrong medication. On 3/6/2024 at 3 PM, LVN 2 stated on 2/27/2024 she saw Family Member 1 inside Resident 1’s room and the Administrator informed him he could not be here. Family Member 1 was walking to go out, he turned back towards Resident 1 and slapped her. Family Member 1 called the resident’s name and stated ‘this is all your fault.’ LVN 2 stated she was scared. Once escorted out, Family Member 1 was outside screaming and yelling. During an interview on 3/6/2024 at 3:30 PM, the Administrator stated Family Member 1 arrived at the facility on 2/26/2024 around 9 AM. The staff heard shouting from Resident 1's room and asked Resident 1 what happened. Resident 1 stated, "He slapped me." Family Member 1 was escorted out of the facility by the police. The Administrator further stated that on 2/27/2024 (the next day) Family Member 1 was found again inside Resident 1's room by the morning staff. The Administrator stated as Family Member 1 was escorted out, he went back and slapped Resident 1 a second time. The Administrator stated, "An emergency protective order was initiated on 2/27/2024 until 3/5/2024 against Resident 1's Family Member." Family Member 1 was called multiple times on 3/6/2024. There was no answer and unable to leave a message. A review of the facilities policy and procedure titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," dated 1/2024, indicated the resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. The facility failed to protect the resident’s right and ensure Resident 1, who had diagnoses including encephalopathy was provided protection and free from physical abuse from Family Member 1. Resident 1, reported to the facility staff and police that Family Member 1 slapped her in the face on 2/26/2024. As a result, on 2/27/2024 (the next day), Family Member 1 returned to the facility, was found inside Resident 1's room, and slapped Resident 1 a second time. This placed Resident 1 at further risk of physical abuse from Family Member 1. The above violations had a direct or immediate relationship to the health, safety, or security of Resident 1.