Health inspection·April 25, 2024

F609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(5) Ensure reporting of crimes occurring in federally funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. (i) Annually notifying covered individuals, as defined at section 1150B(a)(3) of the Act, of that individual’s obligation to comply with the following reporting requirements. (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each covered individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. § 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. The following reflects the finding of the California Department of Public Health during the investigation of Facility Reported Incident # 890148 Survey Re-licensing EVENT ID: MV1X11 Representing the Department, HFEN # 48854 State Citation B was written. On 3/20/24 at 11:06 AM the Department of Public Health conducted an unannounced onsite visit at the facility to investigate a facility reported incident regarding allegations patient to patient abuse. The facility failed to: 1. Ensure Patient 2 was free from physical abuse when Patient 1 punched Patient 2 on the right arm on 3/16/24. 2. Conduct an investigation of the alleged incident that occurred on 2/15/24 when Patient 2 reportedly threw a cold cup of coffee at patient 1. 3. Report the abuse to the California Department of Public Health, State Agency in accordance with the facility's policy and procedure when Patient 2 threw a coffee cup at Patient 1 The above failures resulted in Patient 2 experiencing physical abuse by Patient 1 on more than on occasion (2/15/24 and 3/16/24) resulting in the potential for Patient 2 to suffer negative psychosocial outcome such as anger, fear, anxiety, or loss of self-esteem. This failure resulted in the facility under reporting allegations of abuse. A review of Patient 1’s Admission Record indicated the patient was originally admitted to the facility on 10/14/22 with diagnoses that included schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) and encephalopathy (damage or disease that affects the brain). A review of Patient 1’s History and Physical (H&P), dated 4/13/23, indicated the patient did not have the capacity to make decisions or make needs known. A review of Patient 1’s Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 12/18/23, indicated the patient had severe cognitive impairment. The MDS also indicated the patient requires supervision (helper provides verbal cues and/or touching to assist) for mobility such as sit to stand, chair to chair transfers, and walking 10 feet. A review of Patient 1’s Change in condition (CIC), dated 2/15/24 at 2:50 PM, indicated Patient 1 had been aggressive for the past three (3 days) and “threw a cup of coffee to one of the patients. Good thing coffee is cold.” The CIC did not indicate to whom Patient 1 threw the cup of coffee. A review of Patient 1’s Care Plan for agitation, initiated 3/10/24, indicated Patient 1 had episodes of agitation manifested by being combative and trying to hit staff during care. The care plan indicated interventions to monitor patient 1 every shift for signs and symptoms of increased agitation and to monitor Patient 1 for frequent episodes of agitation. A review of Patient 1’s Care Plans for aggressive behavior, initiated 3/16/24, indicated Patient 1 hit Patient 2. There was no other care plan indicating Patient 1 and Patient 2’s previous incident. A review of Patient 2’s Admission Record indicated the patient was originally admitted to the facility on 8/23/16 with diagnoses that included dementia (a disorder of the brain, causing gradual decline in mental ability) and anxiety (feeling of fear, dread, and uneasiness) A review of Patient 2’s H&P, dated 12/5/22, indicated the patient did not have the capacity to understand and make decisions. A review of Patient 2’s MDS, dated 2/20/24, indicated the patient has intact cognition. The MDS also indicated the patient requires maximal assistance (helper does more than half the effort) for mobility in sit to lying, chair to chair transfers, and sit to stand. The MDS also indicated the patient could not attempt to walk 10 feet due to medical condition or safety concerns. A review of Patient 2’s document titled, Change in Condition Evaluation (CIC), dated 3/16/24, timed at 10:33 PM, indicated the patient was “hit on her [right] arm by [Patient 1] while sitting on her wheelchair inside her room with no reason at all as reported by [Patient 3].” A review of Patient 2’s care plan, initiated on 3/16/24, indicated Patient 2 was hit on her right arm by “another patient.” The care plan indicated to provide safety to Patient 1 and conduct frequent visual checks. There were no other care plans indicating a previous incident between Patient 2 and Patient 1. A review or Patient 3’s Admission Record indicated the patient was originally admitted to the facility on 4/13/15 with diagnoses that included chronic kidney disease (progressive damage and loss of function in the kidneys) and kidney failure (one or both of your kidneys no longer function well on their own). A review of Patient 3’s MDS, dated 12/8/23, indicated the patient had intact cognition. A review of Patient 4’s Admission Record indicated the patient was originally admitted to the facility on 3/19/17 with diagnoses that included diabetes mellitus (elevated blood sugar levels) and hypertension (elevated blood pressure). A review of Patient 4’s H&P, dated 5/6/23, indicated the patient had the capacity to understand and make decisions. A review of Patient 4’s MDS, dated 2/22/24, indicated the patient had intact cognition. During an interview on 3/20/24 at 11:34 AM with Patient 2, Patient 2 stated she got “punched on the right arm a few days ago” by Patient 1. Patient 2 stated the same patient, Patient 1, “threw coffee at her about a month ago in the hallway.” Patient 2 stated she was “hit by the Styrofoam cup and got wet with the coffee.” During an interview on 3/20/24 at 11:38 AM with Patient 3, Patient 3 stated he was aware that Patient 1 punched Patient 2 on the right arm because he reported the incident to a (unnamed) nurse on 3/16/24. Patient 3 stated Patient 1 had another incident involving Patient 2 where Patient 1 threw a cup of coffee at Patient 2. Patient 3 stated always seeing Patient 1 moving around in the facility on his wheelchair. During an interview on 3/20/24 at 11:42 AM with Patient 4, Patient 4 stated she was aware Patient 1 threw a cup of coffee at Patient 2. Patient 4 stated she often saw Patient 1 moving around in the facility on his wheelchair unattended. During a concurrent interview and record review on 3/20/24 at 12:16 PM, Patient 2’s progress notes, dated 2/1/24 to 3/20/24, was reviewed. The DON stated there was no documentation indicating the altercation between Patient 1 and 2 on 2/15/24. The DON stated there were no documentation that indicated Patient 2 was assessed, or a CIC was completed regarding the incident between Patient 1 and Patient 2 on 2/15/24. The DON stated there was no documentation that Patient 2’s physician was notified, and no other investigation was conducted regarding the patient-to-patient altercation on 2/15/24 between patient 1 and 2. The DON stated there was no care plan initiated for the incident on 2/15/24. The DON stated if staff had investigated the incident on 2/15/24 and updated the care plan, proper precautions and interventions could have been in place to prevent the incident that occurred on 3/16/24 when Patient 1 punched Patient 2 on the right arm. During an interview on 3/20/24 at 12:51 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated if an altercation between two patients occurred, both patients must be assessed for injuries. LVN 1 stated an investigation of the incident must be completed and documented to prevent another incident from occurring in the future. During an interview on 3/20/24 at 12:55 PM with RN 2, RN 2 stated altercations between two patients was abuse. RN 2 stated abuse should be reported within two hours of when staff are made aware. RN 2 stated allegations of abuse must be reported to the Director of Nursing (DON), administrator, and the Department of Public Health (DPH). RN 2 stated an investigation was conducted to ensure the safety for the patients and prevent further abuse. During an interview on 3/20/24 at 1:29 PM with LVN 3, LVN 3 stated if an altercation between two patients occurred, a change in condition must be done in the chart for both patients. LVN 3 stated the CIC was done for incidents such as a change in a patient’s condition or an altercation between two patients. LVN 3 stated if the CIC was not done for both patients, then the investigation was incomplete and there was a risk for altercations to happen again in the future. During an interview on 3/20/24 at 2:59 PM with Social Services Director (SSD), SSD stated she was not aware of the incident that occurred on 2/15/24 involving Patient 1 throwing a cup of coffee at Patient 2. SSD stated the incident should have been reported and an investigation should be completed. A review of the facility’s policy and procedure (P&P) titled, “Abuse Investigation and Reporting”, revised 7/17, indicated all reports of patient abuse, shall be promptly reported to local, state, and federal agencies, and thoroughly investigated by facility management.” The P&P indicated the Administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. The P&P indicated an alleged violation of abuse will be reported immediately but not later than “two (2) hours if the alleged violation involved abuse OR has resulted in serious bodily injury.” A review the facility’s policy and procedure (P&P) titled, “Patient-to-patient Altercations”, revised 12/16, indicated staff to “report incidents, findings, and corrective measures to appropriate agencies.” The facility failed to: 1. Ensure Patient 2 was free from physical abuse when Patient 1 punched Patient 2 on the right arm on 3/15/24. 2. Conduct an investigation of the alleged incident that occurred on 2/15/24 when Patient 2 reportedly threw a cold cup of coffee at Patient 1. 3. Report the abuse to the California Department of Public Health, State Agency in accordance with the facility's policy and procedure when Patient 2 threw a coffee cup at Patient 1 The above failures resulted in Patient 2 experiencing physical abuse by Patient 1 on more than on occasion (2/15/24 and 3/16/24) resulting in the potential for Patient 2 to suffer negative psychosocial outcome such as anger, fear, anxiety, or loss of self-esteem. This failure resulted in the facility under reporting allegations of abuse. The above violations cause or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Patient 2.