Health inspection·January 23, 2024

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. 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 12/12/2023 the California Department of Public Health made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about abuse. The facility failed to prevent physical and verbal abuse for Resident 1 and Resident 2. On 12/3/2023 at around 7 p.m. Resident 2 bumped his wheelchair into Resident 1’s wheelchair, subsequently Resident 1 and Resident 2 got into an exchange of verbal profanity against each other and punched each other’s face with close fist several times. As a result, Resident 1 and Resident 2 were subjected to physical and verbal abuse by one another while under the care of the facility. Resident 1 sustained redness to the left check and Resident 2 had swelling to the left cheek needing cold compress. Resident 2 stated feeling defenseless during the assault and was not able to protect himself due to his limited mobility of his left arm. A review of Resident 1's Admission Record indicated the facility admitted the 73-year-old male resident on 11/9/2023, with diagnoses including essential (primary) hypertension, anxiety disorder (persistent and excessive worry that interferes with daily activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/15/2023, indicated Resident 1 had the ability to understand and be understood, make his needs known, and had some memory problem. The MDS indicated Resident 1 required limited to extensive assistance with toileting hygiene and shower and / or bathing and partial assistance with upper body dressing and personal hygiene. Resident 1 used a wheelchair and a walker as mobility devices. A review of Resident 1’s Situational Background Assessment Recommendations (SBAR - communication form between members of the health care team caring for a resident about his / her condition), dated 12/3/2023, indicated that around 7 p.m. Certified Nursing Assistant (CNA 1) informed supervisor about a verbal and physical altercation between Residents 1 and 2. Resident 1 stated he was chatting with CNA 1 in hallway when Resident 2 pushed Resident 1from behind and then, Resident 1 hit Resident 2 hit him. Resident 1 was assessed and was found to have redness on the left cheek. A review of Resident 1’s Psychiatric Examination, dated 12/5/2023, indicated the chief complaint was the physical fight with another resident (12/3/2023) with no injuries. Resident 1 denied any pain or concerns. A review of Resident 2's Admission Record indicated the facility admitted the 51-year-old male resident on 2/17/2023, with diagnoses including left hemiplegia (severe or complete loss of strength on one side of the body) following cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply), abnormality of gait and mobility, and essential hypertension. A review of Resident 2's MDS, dated 12/21/2023, indicated Resident 2 had the ability to understand and be understood and had some memory problems. The MDS indicated Resident 2 required substantial assistance with toileting hygiene and shower and / or bathing and partial assistance with upper body dressing and personal hygiene. Resident 2 use a walker and a wheelchair for mobility. A review of Resident 2’s SBAR, dated 12/3/2023, indicated that around 7 p.m., CNA 1 informed the supervisor that Residents 1 and 2 were exchanging words. Resident 2 stated he was trying to wheel himself through the hallway and he accidentally pushed (or bumped) Resident 1’s wheelchair and Resident 1 started hitting him (Resident 2). Resident 2 stated he hit Resident 1 back defending himself (Resident 2). Resident 2 was noted with swelling to the left cheek and was treated with cold compress. A review of Resident 2’s Skin and Body Assessment, dated 12/3/2023, indicated physical altercation with another resident and slight swelling to the left cheek. A review of Resident 2’s Psychiatric Examination, dated 12/5/2023, indicated the chief complaint was the physical fight with another resident (12/3/2023) with no injuries. Resident 1 denied any pain or concerns. During an interview on 12/12/2023 at 10:25 a.m., Resident 2 stated he could not recall when incident occurred, but it was in the evening he was looking for assistance to get back into bed. Resident 2 stated he was in his wheelchair in hallway and Resident 1 was in hallway speaking to CNA 1 blocking the hallway with his wheelchair. Resident 2 stated he tried to get around Resident 1 but Resident 1 jerked his wheelchair and both wheelchairs made contact. Resident 2 stated that Resident 1 turned around and with a closed fist punched him (Resident 2) on the left eye and pulled on his bag he had around his neck. Resident 2 denied hitting Resident 1 back and stated he only put his right arm up in attempt to protect himself. Resident 2 stated he was given an ice pack, Resident 2 stated he felt defenseless during the assault, he was not able to protect himself due to his stroke and limited mobility of his left arm and leg. During an interview on 12/12/2023 at 11 a.m., Resident 1 stated he did not recall date of incident, but he remembered being outside of his room sitting in the wheelchair and another resident (Resident 2) hit his wheelchair from behind so hard he (Resident 1) almost fell out of his wheelchair. Resident 1 stated he asked Resident 2 what was happening, and Resident 2 replied with profanity, and he (Resident 1) responded back with profanity. Resident 1 stated that Resident 2 then backhanded him in the mouth, and he reacted by smacking Resident 2 back. Resident 1 stated staff (did not identify the staff) separated both. Resident 1 stated he was offered an ice pack for his cheek which was red, but he refused. Resident 1 denied pain or feeling scared. During an interview on 12/12/2023 at 12:33 p.m., CNA 1 stated that on 12/3/2023 around 7 p.m. she was speaking to Resident 1 in hallway and Resident 2 came into hallway in his wheelchair and hit Resident 1 on his wheelchair from behind. CNA 1 stated Resident 1 asked Resident 2 why he pushed him and ask Resident 2 to say, “excuse me.” Both residents got into an exchange of foul language, cussing at each other then they started punching each other in the face. CNA 1 stated she tried to separate them but was unable and called for help while staying with Residents 1 and 2. CN 1 stated Licensed Vocational Nurse 1 (LVN 1) and other staff came to help. CNA 1 stated Resident 1 had a red mark on his face but did not complaint of pain. CNA 1 stated the incident was both physical and verbal abuse, it was unpredictable and occurred fast. During a telephone interview on 12/12/2023 at 1:10 p.m., LVN 1 stated that on 12/3/2023 around 7:30 p.m., he was walking out of a resident room when he heard CNA 1 calling for help. LVN 1 stated he saw Resident 1 and Resident 2 both in wheelchairs punching and yelling at each other. LVN 1 stated he assisted with separating both residents. Resident 1 had redness to the left cheek without complaint of pain, refused first aid, and was mad. LVN 1 stated Resident 2 was upset had redness to left cheek and was provided with cold compress. LVN 1 stated he witnessed both verbal and physical abuse but mostly physical abuse. LVN 1 stated he could not tell how many times they hit each other, and both were punching each other with close fists. During an interview on 12/12/2023 at 2:58 p.m., the Director of Nursing (DON) stated was made aware of incident between Residents 1 and 2 on 12/3/2023 around 7:30 p.m. to 8 p.m. and was told it was a physical altercation. A review of facility's policy and procedures titled, "Abuse Prevention Program," last revised on 8/2006 indicated resident have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Our facility is committed to protecting our residents from abuse by anyone. The facility failed to prevent physical and verbal abuse for Resident 1 and Resident 2. On 12/3/2023 at around 7 p.m. Resident 2 bumped his wheelchair into Resident 1’s wheelchair, subsequently Resident 1 and Resident 2 got into an exchange of verbal profanity against each other and punched each other’s face with close fist several times. As a result, Resident 1 and Resident 2 were subjected to physical and verbal abuse by one another while under the care of the facility. Resident 1 sustained redness to the left check and Resident 2 had swelling to the left cheek needing cold compress. Resident 2 stated feeling defenseless during the assault and was not able to protect himself due to his limited mobility of his left arm. The above violations had a direct relationship to the health, safety, or security of Resident 1 and Resident 2.