Health inspection·September 19, 2022

§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; §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 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 6/15/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident about resident-to-resident abuse. The facility failed to ensure Resident 1 was free from physical abuse inflicted by Resident 2 and was provided with supervision and a safe environment. On 6/13/2022 around 7:15 p.m., while Residents 1 and 2 were unsupervised at the smoking patio, Resident 2 hit Resident 1 with a plastic chair. As a result, Resident 1 sustained an abrasion (an area of the skin damaged by scraping or wearing away) to his left forehead. A review of Resident 1's Admission Record indicated the facility admitted the 79-year-old male resident on 6/30/2021, with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), and psychosis (mental disorder characterized by a disconnection from reality). A review of Resident 1's Care Plan initiated on 6/30/2021 for the resident's potential for increasing confusion related to Alzheimer ' s and dementia, and at risk for wandering and / or elopement (unauthorized departure of a patient from an around-the-clock care setting). The interventions included monitoring Resident 1 for unsteady gait or balance, keeping the environment hazard free and the call light within reach. A review of Resident 1's Care Plan initiated on 7/1/2021 for the resident's risk for wandering and or elopement, the interventions including keeping the environment safe and free from potential hazard, monitoring and documenting resident's whereabouts during each shift. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 4/4/2022, indicated the resident was unable to understand and make decisions and had wandering behavior (occurs when a person roams around with no purpose and becomes lost or confused about their location) occurred daily. Resident 1 required supervision with locomotion on and off unit. A review of Residents 1's SBAR (Situation, Background, Assessment, and Recommendation, is a technique used to provide a framework for communication between members of the health care team) Communication Form and Progress Note, dated 6/13/2022 timed at 7:46 p.m., indicated staff saw another patient striking Resident 1 with a chair in the smoking patio. Resident 1 was unable to provide events leading to this episode and was noted with abrasion on the left side forehead measuring two centimeters (cm) in length by 1 cm in width and by 0.1 cm in depth. The physician when informed ordered triple antibiotic ointment to be applied to the site and skull X-rays (are a type of radiation called electromagnetic waves; x-ray imaging creates pictures of the inside of the body). A review of Residents 1's X-rays results on the same day indicated no broken bones. A review of Resident 2's Admission Record indicated the facility re-admitted the 73-year-old male resident on 5/6/2022, with diagnoses including schizoaffective disorder bipolar type (a mental health disorder by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions such as hallucinations [sensing things such as visions, sounds, or smells that seem real but are not] or delusions [refers to a strongly held belief despite evidence that the belief is false]), vascular dementia (a common form of dementia caused by an impaired supply of blood to the brain), and bipolar disorder (a mental condition marked by alternating periods of elation and low mood). A review of Resident 2's MDS, dated 05/13/2022, indicated the resident was unable to make decisions, had delusions, and required supervision with locomotion on and off unit. A review of Resident 2's Care Plan initiated 5/6/2022 for the resident's potential for mood swings with anger outburst due to schizoaffective disorder, bipolar type. The interventions included monitoring for hyperactivity (higher than normal level of activities) and hypoactivity (lower than normal level of activities) levels, notifying the physician if mood swings interfere with functioning, and counseling the resident to help find alternative methods of expressing himself. On 6/14/2122 at 11:25 a.m., Resident 1's left side of the forehead was observed with a red abrasion. Resident 1 was not able to participate in an interview and mumbled incoherent words. A review of the Incident Report written by Certified Nursing Assistant 3 (CNA 3) indicated around 7:15 p.m., CNA 3 heard a loud voice coming from the back of the lobby (smoking patio), she went out and look around for the person who was shouting and found Resident 2 striking Resident 1 with the chair. On 6/15/2022 at 12:20 p.m., during an interview, Charge Nurse 1 (CN 1) stated around 7:10 p.m. she saw Resident 1 was walking around facility passed the Nursing Station and around 7:20 p.m. she heard someone shouting in the patio, CN 1 stated she saw in the surveillance video screen Resident 2 striking Resident 1 with a patio chair, Resident 2 was still holding chair when CNA 3 arrived at patio. On 7/12/2022 at 11:35 a.m., during an interview, CN 2 stated she was in the Nursing Station, observed in the screen Resident 2 with a chair over his head with the intent to hurt Resident 1. On 7/12/2022 at 1:15 p.m., during an interview, the Director or Nursing (DON) stated Resident 2 willfully hit Resident 1. During an interview on 7/12/2022 at 1:32 p.m., with the Administrator (Adm) indicated that with Resident 2 it was not incidental he was trying to hurt Resident 1 thankfully CNA 3 was able to separate them. A review of facility's document Safety and Supervision of Residents, with effective date 1/1/2022, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. A review of the facility's policy and procedure titled, "Abuse Program Policy and Procedure" last reviewed 3/7/2022 indicated the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Abuse: willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. A review of facility's Smoking Policy and Procedures last reviewed on 3/7/2022 indicated designated smoking times at 8:30 a.m., 1:45 p.m., 4:00 p.m., and 6:00 p.m. Smoking would be supervised by activity and / or nursing staff. The facility failed to ensure Resident 1 was free from physical abuse inflicted by Resident 2 and was provided with supervision and a safe environment. On 6/13/2022 around 7:15 p.m., while Residents 1 and 2 were unsupervised at the smoking patio, Resident 2 hit Resident 1 with a plastic chair. As a result, Resident 1 sustained an abrasion to his left forehead. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.