Health inspection·January 17, 2025

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 12/19/2024, CDPH conducted onsite investigation at the facility regarding resident-to-resident abuse. The facility failed to provide protection Resident 1 from physical abuse by a facility staff, by failing to ensure Certified Nursing Assistant (CNA3) did not slap Resident 1 on 12/5/2024. This failure placed all facility residents at risk for further abuse. A review of Resident 1's face sheet (admission record - a document containing demographic and diagnostic information) indicated the 58 year old male was admitted to the facility on 4/25/2024 and was re-admitted on 12/2/2024 with the following medical diagnoses: acute kidney failure (when kidneys suddenly cannot remove waste from the blood), hyperkalemia (a condition where the potassium level in the blood is too high), type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), benign prostatic hyperplasia with lower urinary tract symptoms (difficulty starting to urinate), paraplegia (paralysis of the legs and lower body), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a condition of excessive worry about daily issues and situations). A review of Resident 1's history and physical (H&P - a physician's complete patient examination) dated 8/8/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Sheet (MDS - an assessment tool) dated 11/12/2024, indicated, Resident 1 had the mental ability to make decisions on activities of daily living. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) form dated 12/5/2024, indicated Resident 1 called the local police department at approximately 9:50 AM to report a facility staff member assigned to Resident 1 had slapped the resident on left cheek twice and laughed. The form indicated Resident 1's physician was informed, and a psychiatric consult was ordered. A review of Resident 1's Skin Assessment (inspecting overall skin color and temperature, moisture level, elasticity, and any skin damage) dated 12/5/2024, indicated, Resident 1 did not have any skin issues. A review of Resident 1's Interdisciplinary (IDT - a group of different healthcare professionals working together towards a common goal for a resident) Conference Record, dated 12/5/2024, indicated, Resident 1 was able to make own decisions and that Resident 1 felt comfortable and safe in the facility. The IDT Conference Record indicated Resident 1 was provided room visits by the Social Service Director (SSD) for emotional support, empathy, and ensured Resident 1's needs were met. The IDT Conference Record indicated Activity staff provided a 1:1 room visit and encouraged Resident 1 to participate in 1:1 activity. A review of Resident 1's care plan (a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) with a focus on Resident 1 at risk for pain and discomfort due to an alleged staff slapped Resident 1 on the left cheek with an initiation date of 12/05/2024. The care plan interventions included encouraging Resident 1 to rest if with pain and balance with activity, encouraged Resident 1 to verbalize pain, to handle Resident 1 gently, carefully, and unhurriedly during transfer, mobility, and repositioning. During an interview with Resident 1 on 12/18/24 at 6:26 PM, Resident 1 stated Certified Nursing Assistant 3 (CNA3) came into the resident's room to routinely asked if Resident 1 needed help. Resident 1 stated CNA 3 was asked when [Resident 1's] doctor would release the resident. Resident 1 stated CNA3 replied, "people are here to take care of you, feed you, we change you," Resident 1 replied "yeah but I still wanna find out when [the doctor] is going to release me." Resident 1 stated then without warning, CNA3 slapped Resident 1 on the left cheek "two to three times." Resident 1 asked CNA3 why CNA3 slapped Resident 1 on the left cheek, Resident 1 stated CNA3 "did not say nothing to me, [CNA3] just laughed at me." Resident 1 stated after informing CNA3 that Resident 1 would call 911 to report the incident, "[CNA3] said to me, go ahead." Resident 1 stated "I called 911 right away. I told the operator that I was assaulted and slapped by the CNA." Resident 1 stated the facility staff were not informed of the incident until police department (LAPD) showed up to the resident's room with the Administrator. When Resident 1 was asked how the alleged abuse incident made him feel, Resident 1 stated "I felt violated. I was very vulnerable. No resident should be slapped by any staff, no one." During an interview with CNA2 on 12/19/2024 at 5:18 PM, CNA2 stated Resident 1 was "always nice and cooperative." When CNA2 was asked what potential harm could come to Resident 1 after an alleged physical abuse, CNA 2 stated Resident 1 could have "pain, fear of getting hurt again if the incident was reported." During an interview with Licensed Vocational Nurse 5 (LVN 5) on 12/19/2024 at 5:32 PM, LVN 5 stated Resident 1 "was sometimes in a very good mood and sometimes quiet but always nice to the staff." When LVN 5 was asked why it was never permissible to hit a resident, regardless of the time and reason, LVN 5 stated "because that is assault." LVN 5 was asked what potential harm may happen to Resident 1 because of the alleged physical abuse, LVN 5 stated Resident 1 "maybe will be afraid of getting hurt again when Resident 1 tries to report the incident, may stop being active, isolation." During an interview with Registered Nurse Supervisor 1 (RNS 1) on 12/19/2024 at 5:41 PM, RNS 1 stated staff "can never hit anyone, residents, or staff, regardless of the reason. You could legally get into trouble for assaulting anyone." During an interview with the Administrator (Adm) on 12/19/2024 at 6:07 PM, Adm stated any dispute with residents had to be reported to the supervisor. Adm stated all staff were trained on abuse during their new hire orientation and again throughout their employment. Adm stated prior to hiring a staff, background checks were performed prior to the start of their employment. During a review of CNA3's Abuse and Reporting Orientation (documentation on how and when to report abuse), CNA3 signed the form on 3/20/2024. A review of CNA 3's background check indicated; the background check request was received on 3/20/2024 and CNA 3 had no negative reports. A review of a facility provided "5-Day Facility Investigation" follow up dated 12/5/2024, indicated a summary of the facility's investigation which concluded "Based on the investigation, the incident was substantiated. Based on the witness CNA's statement, resident's cheek was "tapped", which caused resident to call 911. [CNA3] will be terminated and scheduled quarterly abuse training will continue. CNA board was contacted on 12/09/2024 to report CNA and incident." A review of CNA 3's Corrective Action Memo (a formal written notice that informs an employee of a performance issue, the corrective action required, and the consequences if the employee doesn't improve) dated 12/09/2024 indicated, CNA3 violated facility policy and procedure and violated safety rules. The memo indicated "Employee involved in an alleged abuse incident. Incident substantiated" The memo indicated the action to be taken was "termination". The memo indicated CNA3 was contacted by phone informing CNA3 of outcome of the facility's investigation and CNA3's employment with the facility was terminated. A review of the facility's policy and procedure (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled "Abuse Prevention/Prohibition" dated 1/25/2024, indicated, physical abuse is defined as hitting, slapping...The P&P also indicated the facility screens potential employees for a history of abuse, neglect, or mistreating residents. A review of the facility's P&P titled "Background Screening Investigations" revised on 3/2019, indicated "for any individual applying for a position as a CNA, the state nurse aide registry would be contacted to determine if any findings of abuse, neglect, mistreatment of individuals... have been entered into the applicant's file." The facility failed to provide protection Resident 1 from physical abuse by a facility staff, by failing to ensure CNA3 did not slap Resident 1 on 12/5/2024. This failure placed all facility residents at risk for further abuse. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.