Health inspection·September 18, 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 § 72315 Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22 CCR § 72527 Patient's 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. (11) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 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 8/1/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility-reported-incident regarding resident-to-resident altercation. The facility failed to ensure Resident 3 was not subjected to a physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for a second time by Resident 4, who was physically abusive. The facility failed to: 1. Ensure Resident 4 did not hit Resident 3's left leg with his (Resident 4) wheelchair on 7/19/2023. 2. Ensure the facility's policy and procedures (P&P) titled "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," were followed to ensure Resident 3 was free from physical abuse. As a result, Resident 3 was subjected to physical abuse by Resident 4 while resulting in Resident 3's left leg pain requiring pain medication. A review of Resident 3's Admission Record, Record indicated, the 52-year-old male resident, was admitted to the facility on 12/27/2023, with diagnoses including depression (is a common and serious medical illness that negatively affects how you feel, the way you think, and how you act), hypertension ([HTN] high blood pressure), and other abnormalities of gait (manner of walking or moving on foot) and mobility (the ability to move or be moved freely and easily). A review of Resident 3's Physician's Order Summary Report, dated 12/28/2023, indicated an order dated 12/28/2023, for Tylenol tablet 500 milligrams ([mg]- a unit of measure) two tablets for moderate to severe pain rated 5 out of 10 on a pain rating scale. A review of Resident 3's History and Physical, dated 1/06/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 3's Minimum Data Set ([MDS] - a standardized assessment and care-screening tool), dated 7/3/2024, indicated the resident's cognitive skills (ability to understand and make decisions) for daily decision making were intact (not affected). The MDS indicated Resident 3 required supervision or touching assistance for oral hygiene and rolling left and right. The MDS indicated Resident 3 required moderate assistance with upper body dressing, personal hygiene, and substantial/maximal assistance with toileting, shower/bathe, lower body dressing, putting on/taking off footwear, sit lying, lying to sitting on the side of bed, and sit to stand. A review of Resident 3's Change in Condition (COC) Evaluation, dated 7/4/2024, indicated the resident was heard at the Station 2 hallway reporting that he was hit by Resident 4 on the right forehead resulting in two to three pain level on a pain scale from zero to 10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain possible). A review of Resident 3's Progress Notes, dated 7/4/2024 timed at 6:04 p.m., indicated at 3:30 p.m., Resident 3, while in a wheelchair, wheeled himself outside Resident 4's room where LVN 5 was with Resident 4. LVN 5 witnessed Resident 3 and Resident 4 talking to each other when Resident 3 tapped Resident 4's right knee and Resident 4 complained of pain and punched Resident 3's right side of the head. A review of Resident 3's COC, dated 7/19/2024, indicated Resident 3 reported that Resident 4 kicked Resident 3's left leg and left side of his abdomen on 7/19/2024 in the afternoon (time not indicated). The COC indicated Resident 3 had no signs of injury but complained of moderate pain rated 5 out of 10 in his left leg and asked for pain medication. A review of Resident 3's Medication Administration Record (MAR), dated 7/19/2024, and timed 5:45 p.m., indicated the resident received Tylenol 500 mg two tablets for moderate to severe pain rated 5 out of 10 on a pain rating scale. A review of Resident 4's Admission Record, indicated the 68-year-old male resident was initially admitted to the facility on 8/26/2020 and readmitted on 6/23/2023 with diagnoses including depression, hypertension, and personal history of other mental and behavior disorders. A review of Resident 4's History and Physical, dated 1/06/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 4's MDS, dated 5/30/2024, indicated the resident's cognitive skills for daily decision making were intact. The MDS indicated Resident 4 required supervision or touching assistance for oral hygiene. The MDS indicated Resident 4 required moderate assistance with upper body dressing, personal hygiene and substantial/maximal assistance with transferring, showering, toileting, and lower body dressing. A review of Resident 4's COC Evaluation, dated 7/4/2024, indicated the Licensed Vocational Nurse (LVN 5) reported that Resident 4 had a physical aggression towards Resident 3. During an interview on 8/1/2024 at 11:37 a.m., the Social Services Director (SSD) stated that she talked to Resident 3 on 7/22/2024. The SSD stated Resident 4 was transferred to general acute care hospital 1 (GACH 1) on 7/20/2024 due to aggressive behavior and returned to the facility same day. The SSD also stated that on 7/22/2024, Resident 3 reported to her (SSD) that he (Resident 3) observed Resident 4 going up and down the nurses' station using his (Resident 4) wheelchair when he (Resident 3) was sitting in front of his (Resident 3) room. Resident 3 stated Resident 4 headed back towards Resident 3 and tried to kick him (Resident 3) with his (Resident 4) raised left leg. Resident 4's wheelchair ended up hitting Resident 3's left leg. The SSD stated staff saw what happened and immediately separated the residents. The SSD also stated Resident 4 was transferred out to GACH 2 on 7/23/2024 due to concerns about Resident 4's cognition and physical aggression. During an interview on 8/1/2024 at 1:13 p.m., Resident 3 recalled the altercation between him and Resident 4 on 7/19/2024. Resident 3 stated while he was sitting in his wheelchair in the hallway in front of his room, Resident 4 went past him (Resident 3) five times in his (Resident 4) wheelchair and then he (Resident 4) tried to kick him (Resident 3) with his (Resident 4) raised left leg and missed; however, Resident 4's wheelchair hit his (Resident 3) left leg. Resident 3 stated that Resident 4 tried to push his (Resident 3) face, but Licensed Vocational Nurse 1 (LVN 1) immediately came and took Resident 4 to his (Resident 4) room. Resident 3 stated that his left leg hurt after the incident and LVN 1 gave him (Resident 3) Tylenol for the pain and offered him (Resident 3) an ice pack. Resident 3 stated the incident was the second time that Resident 4 had hurt him (Resident 3). Resident 3 stated that he had no injuries to his left leg. Resident 3 stated that he had no interaction with Resident 4 after the incident, and Resident 4 was being monitored by staff continuously. Resident 3 stated that he feels safe in the facility but not when Resident 4 attacked him. During an interview on 8/1/2024 at 3:23 p.m., LVN 1 stated that on 7/19/2024 at around 5 p.m., Resident 4 was trying to strike out at Resident 3 and she separated the residents. LVN 1 stated she saw Resident 3 was hit in the left leg with Resident 4's wheelchair. LVN 1 stated she gave Resident 3 Tylenol for his left leg pain. LVN 1 stated Resident 3 had no injuries, redness, or skin breakdown. LVN 1 stated that Resident 4 was never hit or kicked by Resident 3 or by anyone. LVN 1 stated that Resident 4 was placed on one-to-one supervision and taken to his room. LVN 1 stated that abuse should never happen in the facility; sometimes it can be hard to prevent, but no resident should be abused in the facility. During an interview on 8/5/2024 at 12:01 p.m., Resident 3 stated that he needed pain medication for the first three days for his left leg after the incident with Resident 4. During an interview on 8/5/2024 at 1:19 p.m., the Administrator (ADM) stated the facility's job is to protect and prevent abuse from happening to residents and the abuse should not have happened between Resident 3 and Resident 4. The ADM stated that no one should be abused in the facility. A review of undated facility's P&P titled "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," indicated, "Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms." The facility failed to: 1. Ensure Resident 4 did not hit Resident 3's left leg with his (Resident 4) wheelchair on 7/19/2023. 2. Ensure the facility's P&P titled "Abuse, Neglect, Exploitation and Misappropriation Prevention Program," were followed to ensure Resident 3 was free form physical abuse. As a result, Resident 3 was subjected to physical abuse by Resident 4 resulting in Resident 3's left leg pain requiring pain medication. The above violation had direct or immediate relationship to the health, safety, or security of Resident 3.