Health inspection·December 6, 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 10/23/2024, 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 protect Resident 9's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another). On 10/17/2024 at 7:30 p.m., Certified Nursing Assistant 4 (CNA 4) witnessed Resident 10's left arm was around Resident 9's neck from behind, while Resident 10 punched Resident 9 with his (Resident 10) right closed fist multiple times on the face while Resident 9 was sitting on the wheelchair watching television (TV) in their (Resident 9 and Resident 10's) room. As a result, Resident 9 was subjected to physical abuse by Resident 10 while under the care of the facility. Resident 9 sustained swelling on the lips with bleeding and pain. Based on the Reasonable Person Concept (the usual behavior of an average person under the same circumstances), due to Residents 9's severely impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) and medical condition, an individual subjected to physical abuse may have physical pain, psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for own self). During a review of Resident 9's Admission Record, the Admission Record indicated the facility admitted Resident 9, a 64-year old male resident, on 9/16/2024 with diagnoses including aphasia (a disorder that makes it difficult to speak) following cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), abnormalities of gait (the manner of walking or moving on foot) and mobility (the ability to move freely and easily), and muscle weakness. During a review of Resident 9's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/23/2024, the MDS indicated Resident 9's cognition was severely impaired. The MDS indicated Resident 9 had little interest or pleasure in doing things, feeling down, depressed (in a state of general unhappiness), or hopeless for 12 to 14 days or nearly every day. The MDS indicated Resident 9 felt bad about self, a failure or let self or family down for 12 to 14 days or nearly every day. The MDS indicated Resident 9 sometimes felt lonely or isolated from those around the resident. During a review of Resident 9's Change in Condition (COC - a significant change in resident's health status) Evaluation, dated 10/17/2024, the COC Evaluation indicated that on 10/17/2024 at 7:30 p.m., the resident (Resident 9) received physical abuse from another resident (Resident 10). The COC Evaluation indicated Resident 9 was found sitting in a wheelchair watching TV when Resident 10 hit Resident 9 on the face. Resident 9 sustained swelling on the lips and had a five out of 10 pain level on the pain scale (a common scale that uses numbers from zero to 10, with zero representing no pain and 10 representing the worst possible pain). The COC Evaluation indicated Resident 9 required ice pack to be placed on the swollen lip. The COC Evaluation indicated Resident 9's Attending Physician was notified at 8:41 p.m. on 10/17/2024. During a review of Resident 9's Progress Notes, dated 10/17/2024, the Progress Notes (documented by Licensed Vocational Nurse 2 [LVN 2]) indicated that on 10/17/2024 at 7:30 p.m., he (LVN 2) was called inside Resident 9 and Resident 10's room (Resident 9 and Resident 10 were roommates). Resident 9's Progress Note indicated CNA 4 witnessed Resident 10 held Resident 9's neck from behind. The Progress Notes indicated Resident 10 punched Resident 9 multiple times with a closed fist (the Progress Note did not indicate which fist). The Progress Notes indicated Resident 9 was noted with swollen lips. During a review of Resident 10's Admission Record, the Admission Record indicated the facility admitted Resident 10, a 83-year old male resident, on 3/31/2021 with diagnoses including encephalopathy (damage or disease that affects the brain), rhabdomyolysis (the breakdown of muscle tissue that leads to the release of muscle fiber into the blood), and paranoid schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 10's MDS dated 9/30/2024, the MDS indicated Resident 10's cognition was severely impaired. During a review of Resident 10's Care Plan (untitled), last revised on 1/4/2023, indicated the resident (Resident 10) was noted with aggressive behavior and getting upset for no reason. The interventions included were to re-direct resident behavior and for the resident not to hurt others or damage property. During a review of Resident 10's History and Physical (HP), dated 4/29/2024, the HP indicated the resident had the capacity to understand and make decisions. During a review of Resident 10's Care Plan (untitled), last revised on 9/30/2024, indicated the resident (Resident 10) had mood swings with poor impulse control. The Care Plan interventions included were to monitor, record, and report to the physician risk for harming others, increased anger, labile mood (rapid, often exaggerated changes in mood occur), or agitation (a state of anxiety or nervous excitement), feeling threatened by others or thoughts of harming someone. During a review of Resident 10's Physician Orders, dated 9/28/2024, the Physician Order indicated to monitor behavior episodes of sudden outburst of anger and tally with hashmark for each episode on the Medication Administration Record (MAR - a report detailing the medications administered to a resident) every shift. During a review of Resident 10's MAR, dated 10/1/2024 to 10/31/2024, the MAR indicated that on 10/14/2024 on the 11 p.m. to 7 a.m. shift, Resident 10 had two episodes of anger outburst. During a review of Resident 10's COC Evaluation, dated 10/17/2024, the COC Evaluation indicated on 10/17/2024 at 7:30 p.m., Resident 10 was witnessed behind Resident 9 while hitting the resident (Resident 9) on the face multiple times. During an interview on 10/24/2024 at 9:58 a.m. with Resident 9, Resident 9 stated another resident punched him on the face. Resident 9 was not able to provide other information about the incident. During a telephone interview on 10/24/2024 at 10:12 a.m. with CNA 4, CNA 4 stated she (CNA 4) heard Resident 9 yelling inside the resident's room. CNA 4 stated she (CNA 4) then went inside Resident 9's room and found Resident 9 sitting on a wheelchair. CNA 4 stated Resident 10's left arm was around Resident 9's neck, while Resident 10 punched Resident 9's face with his (Resident 10) right closed fist multiple times. CNA 4 stated that Resident 10's punches were hits and misses on Resident 9's right cheek, right jaw, and right side of the mouth area. CNA 4 stated Resident 9 and Resident 10 were separated. CNA 4 stated Resident 9 had blood (amount not indicated) in the mouth and in the right lower lip that required an ice pack. CNA 4 stated Resident 10 punching Resident 9 is physical abuse. During a telephone interview on 10/24/2024 at 12:26 p.m. with LVN 2, LVN 2 stated he heard someone screaming at Station 1 LVN 2 stated that when he (LVN 2) entered inside Resident 9 and Resident 10's room, both residents were already separated. LVN 2 stated CNA 4 witnessed Resident 10 punching Resident 9 on the face. LVN 2 stated Resident 9's middle part of the lower lip was bleeding requiring an ice pack to be placed on the lips to prevent swelling and to stop the bleeding. LVN 2 stated Resident 10 had a history of aggressive behavior towards another resident. LVN 2 stated that Resident 10 punching Resident 9 is physical abuse. During an interview on 10/24/2024 at 12:38 p.m. with the Director of Nursing (DON), the DON stated residents should be free from abuse. The DON stated the physical act of intentionally punching a person is physical abuse. Resident 10 punching Resident 9 was considered as an abuse. The DON stated the facility failed to prevent the physical act of abuse from happening between Resident 9 and Resident 10. During a review of the facility's policy and procedure (PnP) titled, "Abuse, Neglect (fail to care properly), Exploitation (the act of using someone or something unfairly for your own advantage) and Misappropriation (to steal something that you have been trusted to take care of and using it for yourself) Prevention Program," last reviewed on 4/2024, the PnP indicated the resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The PnP indicated that it included freedom from ... verbal, mental, sexual, or physical abuse .... The PnP indicated the facility objective to protect residents from abuse by anyone including ... b. other residents. The facility failed to protect Resident 9's right to be free from physical abuse. On 10/17/2024 at 7:30 p.m., CNA 4 witnessed Resident 10's left arm was around Resident 9's neck from behind, while Resident 10 punched Resident 9 with his (Resident 10) right closed fist multiple times on the face while Resident 9 was sitting on the wheelchair watching TV in their (Resident 9 and Resident 10's) room. As a result, Resident 9 was subjected to physical abuse by Resident 10 while under the care of the facility. Resident 9 sustained swelling on the lips with bleeding and pain. Based on the Reasonable Person Concept, due to Residents 9's severely impaired cognition and medical condition, an individual subjected to physical abuse may have physical pain, psychological effects including feelings of hopelessness, helplessness, and humiliation. The above violation had direct or immediate relationship to the health, safety, or security of Resident 9.