Other·July 10, 2023

F600 §483.12 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.

F610 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

F684 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following: On 5/25/2023 at 9:59 A.M., an unannounced visit was made by the California Department of Public Health (CDPH) to the facility to investigate a complaint regarding accidents, patient safety, and abuse. Specifically, involving a sampled patient (Patient 1) who was assessed as having moderately impaired cognition (thought process) and limited assistance with transfers. As a result of the investigation, the Department determined that the facility failed to: 1. Ensure the facility conducted a thorough investigation of a patient-to-patient altercation between Patients 1 and 2 on 5/23/23, in accordance with the facility’s policy on “Abuse-Reporting & Investigations.” 2. Assess Patient 1’s overall condition utilizing a physical assessment, that included the patient’s neurological status, after a patient-to-patient altercation that resulted to a fall on 5/23/23, and in accordance with the facility’s policy on “Change of Condition Notification.” 3. Monitor Patient 1 for bleeding, bruising, discoloration, and other complications, in accordance with resident’s care plan for the use of Eliquis (medication use to prevent serious blood clots; blood thinner), after a patient-to-patient altercation between Patients 1 and 2 on 5/23/23, that resulted to a fall. 4. Ensure that Patient 1’s attending physician (Physician 1) was notified of Patient 1’s change of condition. Registered Nurse (RN) 1 did not notify Physician 1 of Patient 1’s injuries manifested by left face swelling, bruising to the left cheek, swollen and painful left arm, after a patient-to-patient altercation between Patients 1 and 2 on 5/23/23, that resulted to a fall, in accordance with the facility’s policy on “Change of Condition Notification.” On 5/23/23, Patient 1, who was assessed as having moderate impairment in cognition, was found on the floor by the Emergency Medical Technicians (EMT; a medical professional that provides emergency medical services and transport patients to medical facilities) and the facility’s licensed nurses and stated, “That guy (Patient 2) is not nice.” The facility did not conduct a thorough investigation of the incident observed and reported by the EMTs to the facility’s licensed vocational nurse (LVN 1) on 5/23/23. Patient 1 was sent to the Dialysis Center for his scheduled dialysis treatment on the same day (5/23/23), with the left face swollen, bruising to the left cheek, and painful left arm. As a result, Patient 1 had a delay in treatment and the potential to cause permanent complications due to the injuries sustained by Patient 1 on 5/23/23. In addition, other residents had the potential to experience physical abuse from Patient 2 due to the facility’s failure to investigate the abuse allegation thoroughly. On 5/23/23, upon arrival to the Dialysis Center, Patient 1 was sent to the General Acute Care Hospital (GACH) Emergency Department (ED) via 911 emergency services due to dizziness, elevated heart rate, bruised, swollen left under eye, left arm pain, and could not move or lift the fingers. In the GACH, Patient 1 was found to have a 5 millimeter (mm-unit of measurement) intracranial bleed (bleeding to the brain) due to closed head injury (closed head injury is any injury you receive to your head, that does not go through the skull, is a closed head injury. The most common causes of a closed head injury are falls from height or from standing can cause significant injuries. Falls, from height or from standing can cause significant injuries). Resident 1 was admitted to the GACH telemetry for monitoring of his condition and discharged to a different facility after two days. A review of Patient1's Admission Record indicated the 74-year-old male patient was initially admitted to the facility on 5/15/23, with diagnoses that included Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), end stage renal disease (kidney failure), and lack of coordination. A review of Patient1's History and Physical (H&P), dated 5/17/23, indicated Patient 1 had the capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 3/30/23, indicated Patient 1 had moderate impairment in cognition (ability to understand and reason). The MDS indicated Patient 1 required limited assistance (Patient highly involved in activity; staff provide guided maneuvering of limbs or other-non-weight-bearing assistance) with transfer, dressing, toilet use, personal hygiene, and required supervision (oversight, encouragement, and cueing) during bed mobility and eating. A review of Patient 2's Admission Record indicated the 72-year old male patient was initially admitted to the facility on 2/6/23, with diagnoses that included mild cognitive impairment, chronic pain, and lack of coordination. A review of Patient 2's H&P, dated 2/8/23, indicated Patient 2 had fluctuating capacity to understand and make decisions. A review of Patient 2's MDS, dated 2/13/23, indicated Patient 2 had severe impairment in cognition. The MDS indicated Patient 2 required extensive assistance (Patient involved in activity; staff provide weight-bearing support) and required limited assistance with personal hygiene. The MDS indicated Patient 2 required supervision with eating. A review of Resident 1’s care plan for Eliquis dated 5/15/23 indicated Resident 1 was at risk for bleeding related to the use of Eliquis for atrial fibrillation (irregular heartbeat), with an intervention to monitor signs and symptoms of bleeding such as skin discoloration. A review of Patient 1’s “Change of Condition (COC) Evaluation,” dated 5/23/23 timed at 8:48 AM, authored and signed by Registered Nurse (RN) 1 dated 5/24/23 (one day after the incident) indicated Patient 1 had a fall on 5/23/23, without injury or changes in skin condition. The COC indicated Patient 1 stated “That guy is not nice (Patient 2),” but denied that the “guy” pushed him, when asked by the facility staff. The COC indicated Patient 1 was taken by the staff to the Dialysis Center due to “no head injury observed” and no change in Patient 1’s skin condition and range of motion. The COC indicated; Patient 1 denies pain. The COC indicated “Physician 1 informed via messaging.” A review of Patient 1’s Progress Notes, dated 5/23/23 timed at 8:52 AM, documented by RN 1 as late entry, indicated Patient 1 had a witnessed fall on 5/23/23 at 8:39 AM inside Patient 1’s room. The Progress Notes indicated Patient 1 refused assistance, got off balance ambulating to the bathroom, and “might have caught his feet on something, stumbled, and held onto Patient 2.” The Progress Notes indicated Patient 2 shrugged Patient 1 off due to not wanting to be held. The Progress Notes indicated Physician 1 was made aware of the witnessed fall via messaging, replied and ordered that Patient 1 may go to the Dialysis Center and continue to monitor when Patient 1 comes back from dialysis. There was no documentation evidence found on what specific information was provided to Physician 1 by RN 1. A review of Patient 1’s Progress Notes, dated 5/23/23 at 8:59 AM. indicated Patient 1 had a fall incident and was witnessed by EMT staff to “fell on his butt” while talking to Patient 2. The Progress Notes indicated, Patient 1 did not sustain injury upon assessment and was sent to the Dialysis Center on 5/23/23. A review of the Dialysis Center record dated 5/23/23, indicated Patient 1 arrived at the Dialysis Center for his regularly scheduled dialysis treatment and upon assessment Patient 1 stated he was attacked by another patient in the facility. The record indicated Patient 1 had a bruise, swollen left under eye, left arm pain, and could not move or lift the fingers and dizzy. The record indicated the Dialysis Center called 911 emergency services to get Patient 1 evaluated for any other injuries. A review of the Patient Care Report (PCR-911/paramedics report) dated 5/23/23, indicated emergency paramedics arrived at the Dialysis Center on 5/23/23 timed at 11:10 AM, and assessed Patient 1 from head to toe. The PCR indicated Patient 1 was complaining of left cheek pain and had a minor swelling to the cheek. The PCR report indicate Patient 1 reported to the paramedics that he was hit by another patient in the facility. The PCR indicated Patient 1 will be transported to Acute Hospital/ Emergency room for further evaluation. A review of the GACH ED records dated 5/23/23 timed at 5:08 PM, indicated Patient 1 arrived at the GACH ED status post altercation with “somebody” at the facility and sustained trauma to the left side of his face and left arm. Patient 1 was found to have intracranial (within the skull) small bleed and was admitted to inpatient GACH for further evaluation of deterioration. The diagnoses included intracranial bleed and closed head injury. A review of Patient 1’s Computed Tomography scan (CT-imaging technique) of the brain result dated 5/23/23, indicated an impression of “5 millimeter (mm-unit of measurement) acute intraparenchymal hemorrhage (bleeding into the brain) in the left insular cortex (insular lobe-responsible for sensory processing) versus subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) in the adjacent sylvian fissure (basal to the lateral surface of the brain)”. A review of Patient1’s repeat CT scan result dated 5/24/23, indicated an impression of “small posterior (rear) left sylvian fissure subarachnoid blood collection without significant change.” A review of the Police Report dated 5/28/23, indicated Detective 1 investigated the incident due to an abuse allegation. The Police Report indicated Detective 1 went to the GACH and observed that Patient 1 had a black swollen left eye, large black and blue bruise on the lower left portion of Patient 1’s face and chin area. The Police Report indicated Patient 1 stated there were two EMTs on the scene, Patient 2 asked Patient 1 if they were “hookers” and when Patient 1 answered he did not know anything, Patient 2 suddenly punched Patient 1 with a closed fist on the left side of his face. The Police Report indicated that Detective 1 interviewed FM 1 and stated that Patient 2 was angry and unfriendly towards Patient 1. A review of the Ambulance’s “Incident Report” dated 5/31/23, provided to CDPH, indicated two EMT staff (EMT 1 and 2) and one student rider arrived at the facility to pick up and transport Patient 1 to the Dialysis Center on 5/23/23. The Ambulance Incident Report indicated the incident happened on 5/23/23 at 9:15 AM when one EMT staff (EMT 1) was waiting directly outside Patient 1’s room, EMT 1 witnessed Patient 2 grabbed and pushed Patient 1 to the ground. The Ambulance Incident Report indicated Patient 1 was lying on the floor when facility staff rushed and circled around Patient 1, assisted Patient 1on his bed and performed assessment. The Ambulance Incident Report indicated Patient 1 had swelling and redness on his left cheek and was complaining of left arm pain. The Ambulance Incident Report indicated facility staff deemed Patient 1 stable enough to be transported to the Dialysis Center via a gurney. The Ambulance Incident Report indicated Patient 1 complained of dizziness upon arrival to the Dialysis