Other·January 28, 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. 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 7/15/2021 an unannounced visit was made to the facility to conduct a facility reported incident investigation and Resident 2’s care was reviewed. The facility failed to ensure Resident 2, who was placed in the same room with Resident 1, was not subjected to physical abuse inflicted by Resident 1. The facility failed to: 1. Evaluate Resident 2’s safety when it was decided to place him in the same room upon re-admission and after Resident 1 became protective of his room preventing entry of staff which resulted in moving out Resident 3 from Resident 1’s room. 2. Monitor Resident 1 for mood and behavior symptoms that posed a threat to self and others, as the psychosocial evaluation was not done within seven days from admission, per facility’s policy. 3. Implement its policy on abuse to ensure Resident 2 was free from physical abuse. As a result, on 7/5/2021 at 12:55 a.m., while Resident 2 was asleep in bed, Resident 1 hit him with a table on the face and arms. Resident 2 required emergency transfer to general acute care hospital 1 (GACH 1), where he was diagnosed with broken facial bones, broken teeth, left facial hematoma (collection of blood), swelling and laceration (deep cut or tear in the skin) to the left side of the face. Resident 2 stated feeling traumatized, frightened at night, and having difficulty sleeping. A review of Resident 2's Admission Record (Face Sheet) indicated the facility re-admitted the resident, a 72-year-old male on 6/29/2021 with diagnoses including Type II diabetes (a chronic condition that affects the way the body processes blood sugar [glucose], cirrhosis of the liver (chronic liver damage from a variety of causes leading to scarring and liver failure), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). Resident 2 was placed in Resident 1’s room (which was a different room from Resident 2’s previous stay). A review of Resident 2’s Admission Nursing Notes, dated 6/29/2021, indicated the resident was alert and oriented to person, place, and time; and required extensive assistance with activities of daily living (ADLs such as walking, dressing, locomotion, and personal hygiene). A review of Resident 2’s SBAR (Situation, Background, Assessment, Recommendation - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident), dated 7/5/2021, indicated Resident 2 was assaulted by his roommate (Resident 1) at 12:55 a.m. Resident 1 hit Resident 2 on the face, head, and arms. Resident 2 had a cut on the left side of the nose measuring 3.5 cm with blood noted flowing out of the cut and had discoloration to both arms. Resident 2 was removed from the room and placed near Nurses’ Station 1. Paramedics were called and took Resident 2 to GACH 1. A review of Resident 2's After Visit Summary from GACH 1, dated 7/5/2021, indicated Resident 2 had computerized tomography scans (CT scans - a series of X-ray images taken by computers to create more detailed images of bones, blood vessels, and tissues inside the body) of his head. The CT scans indicated Resident 2 had broken facial bones, broken teeth, left facial hematoma, swelling to the left side of the face, and a laceration to the left side of the face. Resident 2 was discharged back to the facility with antibiotic and follow up visit in one week with an otorhinolaryngology specialist (doctor who specializes in in care of the ears, nose, and throat). According to a review of Resident 2’s Progress Notes dated 7/5/2021 at 4:48 p.m., Resident 2 returned to the facility at 12 p.m., from GACH 1, in fair condition with two stitches on the right upper lip and right nares, and a swollen upper palate and lip. A review of Resident 2’s Physician’s Orders dated 7/5/2021 indicated to give Cephalexin (Keflex, an antibiotic medication used to treat bacterial infections) one capsule by mouth twice daily for 10 days and Norco (a medication used to treat moderate to severe pain) 5/325 milligrams 1 tab by mouth every six hours as needed for severe pain, and a psychology consult and treatment. A review of Resident 1's Admission Record (Face Sheet) indicated the facility originally admitted the resident, a 53-year-old male, on 6/24/2021, with diagnoses including paranoid schizophrenia and major depressive disorder. Resident 1 did not have a family member or other responsible party, or emergency contact listed in the face sheet. According to a review of Resident 1's Psychosocial Care Plan developed on 6/28/2021, for the resident’s misdirected anger and diagnosis of paranoid schizophrenia, the goal was not showing anger behavior daily. The interventions included psychiatric consult; assessing for negative emotions, anger, anxiety, and depression; providing emotional support; encouraging expression of feelings; and providing education to the resident and staff about special care needs. A review of Resident 1's SBAR form, dated 6/29/2021 (four days after admission), indicated Resident 1 had a change in behavior in which he denied staff entrance to his room, where he resided with Resident 3. A review of Resident 1's Social Services Progress Note, dated 6/29/2021, indicated Social Services Director 1 (SSD 1) tried to interview Resident 1 and get inside Resident 1's room, but the resident placed something to block the door. SSD 1 explained to Resident 1 he wanted to interview him, and he could not block the door for his safety, but Resident 1 started to get agitated and stated, "I will call the police, I don't want to talk to you." A review of Resident 1's Care Conference notes, dated 7/1/2021, indicated an Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) meeting was held with Resident 1 to discuss respecting his new roommate and facility rules. A review of the Physician’s Orders for Resident 1, between 6/24/2021 and 7/5/2021, indicated there were no orders for the nurses to monitor, every shift, Resident 1 for manifestation of mood problems, hallucinations, delusions, physical, verbal, or other behavioral symptoms or assess emotional state (such hostile, anger, calm, despondent, stress, pleasant, sad, fear, etc.). According to a review of Resident 1's SBAR, dated 7/5/2021, Resident 1 assaulted his roommate (Resident 2) using a table at 12:55 a.m. Resident 2 was in bed. When asked the reason for hitting the roommate, Resident 1 stated, "It's self-defense, he stole my credit card." Resident 2 had a bleeding cut on the left side of the nose measuring 3.5 centimeters (cm) in length and skin discoloration to both arms. Resident 2 was asked what happened and stated, "I don't know, I was just sleeping when he hit me.” The paramedics and police were called. A review of Resident 1’s Progress Notes dated 7/5/2021 at 3:49 a.m., indicated the police took Resident 1 in his wheelchair and he was refusing to go with the officers. On 7/15/2021 at 6:30 a.m., during an observation and concurrent interview, Resident 2 had bruises on the left eye, left arm, left hand, missing teeth, and a laceration to his lip and left nose. Resident 2 stated, "It happened (on 7/5/2021) after midnight. He (Resident 1) came to my side, took the table, and threw it. I woke to the blow on my face. I was disoriented and the table broke. Nine of my teeth broke, my nose was detached from my face. Nurses heard the noise and came to my room and rescued me. I was profusely bleeding. There was no reason to attack me, I never had an argument with him." Resident 2 further stated, "Sometimes I can't sleep at night, because I'm traumatized, I get scared especially at night." During an interview on 7/15/2021 at 6:20 a.m., Registered Nurse Supervisor (RN 1) stated the incident happened on 7/5/2021 at 12:55 a.m. The Charge Nurse heard something and went to see what it was. The Charge Nurse found Resident 1 holding a piece of wood from a bedside table. Both RN 1 and the Charge Nurse saw Resident 2 with blood all over his face and moved Resident 2 out of the room. The Charge Nurse called the paramedics and the police. The paramedics took Resident 2 to GACH 1. The police left with Resident 1 at 4:30 a.m. and Resident 1 did not return to the facility. On 7/15/2021 at 7:50 a.m., during an interview, Director of Nursing 1 (DON 1) stated on 6/29/2021, Resident 3 touched Resident 1’s wheelchair which made him upset so Resident 1 tried to block the door to their room with his wheelchair. On 8/17/2021 at 10 a.m., during an interview, Licensed Vocational Nurse (LVN 2) stated he was the Charge Nurse on the night of the incident (7/5/2021) between Residents 1 and 2. LVN 2 stated, that around 12:45 a.m. he heard three loud sounds. He ran to where the sound came from and saw Resident 1 in the room holding the top of a bedside table and Resident 2 was in bed with “blood all over his face.” Resident 1 stated, "Why did you take my credit card." LVN 2 told Resident 1 “to stay where he was” and got Resident 2 out of the room and called 911. The police took Resident 1. During an interview on 8/17/2021 at 4:29 p.m., Resident 2’s attending physician (MD 1) stated the psychiatrist evaluation and consult were part of the routine orders and the nurses can use them in case a resident needs it. MD 1 stated Resident 1 would have benefited from a psychiatric evaluation and treatment. On 8/18/2021 at 10:15 a.m., during an interview, Resident 3's family member (FM 1) stated he remembered Resident 1 being Resident 3’s previous roommate and Resident 3 was moved to another room because Resident 1 was aggressive and was yelling. FM 1 stated one day Resident 1 blocked the door with a wheelchair to prevent people from entering the room. Resident 1 started yelling, “You’re harassing me, I’m going to call the police,” when he barely opened the door and moved the wheelchair to the side. FM 1 stated FM 2 went to visit Resident 3 the next day and Resident 1 did the same thing. Resident 1 screamed he was being harassed and threatened that his personal property or belongings could not be touched. On 8/19/2021 at 11:19 a.m., during an interview with SSD 2 and concurrent review of Resident 1’s social services documentation, SSD 2 stated that for all admitted residents social services staff performed an initial screening/assessment which included psychosocial evaluation, mood, and behavioral symptoms. The initial social service assessment helped to evaluate if the resident needed psych evaluation. SSD 2 was unable to find Resident 1’s initial social service assessment and confirmed the social service psychosocial evaluation was not done. During an interview with DON 2 on 8/19/2021 at 11:30 a.m., and a concurrent review of Resident 1’s IDT meetings, Physician’s Orders, and Nursing Progress Notes dated 6/24/2021 to 7/5/2021, DON 2 stated and confirmed the documentation did not have evidence the licensed nurses were monitoring and addressing Resident 1’s mood and behavior and implementing interventions as per plan of care. DON 2 acknowledged Resident 1 did not receive psychiatric evaluation and treatment as ordered and as needed due to his diagnoses and behavioral manifestation. Resident 1 did not have any medication to treat his mental illnesses, and the IDT did not meet within 72 hours from admission as per policy. On 12/20/2021 at 2:27 PM, during an interview and concurrent review of Resident 2’s admission date to the facility, DON 1 stated Resident 2 was readmitted to the facility on 6/29/2021 into Resident 1’s room because he was past the number of days for a bed hold (a reservation that allows a resident to stay in, or return to, a care facility) and could not return to his previous room. A review of the facility’s policy and procedures on Resident-to-Resident Altercations, revised 11/1/2015, indicated the facility acts promptly and conscientiously to prevent and address altercations between residents. Facility staff observes residents for aggressive or inappropriate behavior toward other residents, family members, visitors, or facility staff. Any occurrences of such behavior are promptly reported to the Charge Nurse, the Director of Nursing Services, and the Administrator. Response to an altercation: Separate the residents, and institute measures to calm the situation. Determine what happened, including what might have led to aggressive conduct on the part of one or more of the residents involved in the altercation. Notify each resident’s representative and Attending Physician of the incident. Review the events with the Charge Nurse and Director of Nursing Services, including interventions staff can take to prevent additional incidents. Consult with the Attending Physician to identify treatable conditions such as delirium that may have caused to contributed to the problem. Make necessary changes in the Care Plan for any or all of the involved residents as necessary. Document interventions and their effectiveness in the resident’s medical record. Consult with psychiatric or psychological services as needed for assistance in assessing the resident, identifying causes, and developing a Care Plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Team. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident. A review of the facility’s policy and procedures on Interdisciplinary (IDT) Skilled Review, revised 9/5/2017, indicated upon admission, an Admission Skill Meeting form will be initiated. Within 72 hours, the IDT will gather information from the resident, responsible party, or significant other regarding expectations, discharge plans, and goals, etc. The resident's admission baseline status or usual performance will be obtained and documented on AP-23-Form B as based on assessment which includes observation, data collection, etc. A review of the facility’s policy and procedures on Social Service Assessment, revised 12/1/2013, indicated the Director of Social Services or designee will complete a Social Service Assessment for new and readmitted residents with seven (7) days of admission. The Social Services Assessment will address the resident's physical and psychosocial needs that should be considered in developing the resident's plan of care. A review of the facility’s policy and procedures on Comprehensive Person-Centered Care Planning, revised 11/2018, indicated the facility was to provide person-centered, comprehensive, and interdisciplinary care that reflect best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents to obtain or maintain the highest physical, mental, and psychosocial well-being. A baseline care plan will be initiated upon admission by the admitting nurse using the necessary combination of problem specific care pl