Other·February 7, 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 12/26/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a Facility-Reported Incident (FRI) about resident abuse. The facility failed to protect and ensure Resident 1 had the right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm). On 12/21/2023, Resident 2 pulled Resident 1 out of bed causing Resident 1 to fall to the floor. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 2 pulled Resident 1 out of his bed causing Resident 1 to fall onto the floor, to cry, scream, and shake. Based on the reasonable person concept (hypothetical average person's reaction to the actual circumstances) due to Resident 1’s severely impaired cognition (ability to think and make decisions), an individual subjected to physical abuse has lifetime physical pain and psychological effects including feelings of embarrassment and humiliation. A review of Resident 1's Admission Record indicated the facility originally admitted Resident 1 on 2/23/2022 and readmitted on 3/14/2023 with a medical history of psychosis (a condition of the mind that results in difficulties determining what is real and what is not real). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-planning tool) dated 11/2/2023, indicated Resident 1 had severe mental confusion. A review of Resident 1's Situation-Background-Assessment-Recommendation Communication Form (SBAR - a form that provides communication between health care team members about a resident's condition), dated 12/21/2023, indicated the facility noted Resident 1 to be a victim of aggressive behavior when Resident 2 pulled Resident 1 out of bed. The SBAR further indicated that Resident 1 was crying after being pulled out of the bed by Resident 2. A review of Resident 1's Care Plan for Psychosocial Well Being, dated 12/21/2023, indicated that Resident 1 was at risk for alteration in Psychosocial Well-Being as manifested by crying due to Resident 2 pulling Resident 1 out of bed. A review of Resident 2's Face Sheet, dated 7/26/2023, indicated the facility admitted Resident 2 on 11/4/2020 with a medical history of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A review of Resident 2's MDS dated 11/6/2023, indicated Resident 2 had severe mental confusion. A review of Resident 2's SBAR Communication Form, dated 12/21/2023, indicated the facility noted Resident 2 to have aggression towards Resident 1. The SBAR indicated that Resident 2 was aggressive towards Resident 1 by pulling Resident 1 out of bed. The SBAR communication form further indicated that Resident 2's physician ordered the facility to transfer Resident 2 to the General Acute Care Hospital (GACH) for evaluation. A review of Resident 2's care plan for Behavioral Problems, dated 12/21/2023, indicated that Resident 2 exhibited aggressive behavior towards Resident 1 by pulling Resident 1 out of bed. During an interview on 12/26/23 at 9:20 a.m. with Resident 1, when Resident 1 was asked if he was able to recall the incident that occurred on 12/21/2023 where in Resident 2 pulled Resident 1 out of bed onto the floor, Resident 1 did not respond and was noted to be nonverbal. During an interview on 12/26/2023, 9:50 a.m., Licensed Vocational Nurse 2 (LVN 2) stated that on 12/21/2023, LVN 2 heard screaming and crying coming out of Resident 1 and Resident 2’s room. LVN 2 stated that she ran into Resident 1 and Resident 2’s room where she witnessed Resident 2 pull Resident 1 off the resident’s bed causing Resident 1 to fall to the floor. LVN 2 stated that she witnessed Resident 1 crying and shaking as she assisted Resident 1 back to the resident’s bed. LVN 2 stated that she had received training in identifying distress in residents. LVN 2 stated that it appeared as though Resident 1 had suffered from psychosocial harm as the resident was crying and shaking as the result of the incident. During an interview on 12/26/2023 at 10:40 a.m., the Administrator (ADM) stated that the incident that occurred on 12/21/2023, in which Resident 2 grabbed the legs of Resident 1 and pulled Resident 1 out of his bed and on to the floor, causing Resident 1 to cry and shake, was an act of willful abuse. The ADM stated that Resident 1 had a right to be free from all forms of abuse, and because of the incident, Resident 1 was not kept free from abuse while in the facility. During an interview on 12/26/2023 at 10:44 a.m., the Director of Nursing (DON) stated that the incident that occurred on 12/21/2023 where in Resident 2 grabbed the legs of Resident 1 and pulled Resident 1 out of his bed and on to the floor, causing Resident 1 to cry and shake, was an act of willful abuse. The DON stated that Resident 1 had the right to be free from all forms of abuse and that the facility was unable to protect Resident 1 from physical abuse. A review of the facility's policy and procedure titled, “Alleged Abuse Investigation,” dated 2/22/2023, indicated that "Abuse," is defined as a willful infliction of injury resulting in physical harm or pain or mental anguish. The policy further indicated the facility, "will ensure that resident's rights are protected..." The facility failed to protect and ensure Resident 1 had the right to be free from physical abuse. On 12/21/2023, Resident 2 pulled Resident 1 out of bed causing Resident 1 to fall to the floor. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 2 pulled Resident 1 out of his bed causing Resident 1 to fall onto the floor, to cry, scream, and shake. Based on the reasonable person concept due to Resident 1’s severely impaired cognition, an individual subjected to physical abuse has lifetime physical pain and psychological effects including feelings of embarrassment and humiliation. The above violations had a direct relationship to the health, safety, or security of Resident 1.