Health inspection·November 9, 2023

Title 22 § 72315. Nursing Service - Patient Care. 72315 (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. § 72527. Patients' Rights. 72527(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 Abuse and Neglect F600 §483.12 Freedom from Abuse, Neglect, and Exploitation §483.12(a)(1) Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. An unannounced visit was conducted by the California Department of Public Health (CDPH) on 9/26/2023 at 10:35 am to investigate a complaint and a Facility Reported Incident regarding an allegation of sexual abuse (any sexual activity that occurs without consent). The facility failed to ensure Patient 2 was free from sexual abuse (non-consensual sexual contact) on 9/22/2023 around 2 PM when Patient 1 exposed his penis (the male genital organ) and grabbed Patient 2’s breast while in the facility’s Activity Room as observed by Patient 3. These deficient practices resulted in Patient 2 experiencing sexual abuse and unwanted nonconsensual sexual contact from Patient 1. Patient 2, who has a diagnosis of Alzheimer’s (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) did not exhibit a change in behavior due to the sexual abuse but had a potential to suffer a negative psychosocial outcome such as anger, fear, anxiety, or loss of self-esteem using the reasonable person concept (assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the patient’s position). A review of Patient 1’s Admission Record indicated the facility admitted the 91 year old male patient on 7/28/2020, and readmitted on 9/17/2023, with diagnoses that included metabolic encephalopathy an alteration in consciousness caused due to brain dysfunction), unspecified dementia with behavioral disturbances. A review of Patient 1’s History and Physical Examination (HPE) signed and dated by the attending physician on 9/21/2023, indicated the patient did not have the capacity to make decisions. A review of Patient 1’s Minimum Data Set (MDS; a care assessment screening tool) dated 9/07/2023, indicated Patient 1 had impaired memory recall. The MDS indicated Patient 1 required extensive assistance (patient involved in activity; staff provide weight bearing support) with bed mobility, transferring between surfaces, dressing, toilet use and personal hygiene. The MDS indicated Patient 1 required supervision (oversight, encouragement or cueing) while eating. A review of the facility’s September 2023 Activity Schedule indicated that on 9/22/23 at 2 PM the facility’s planned activity with patients was “Juice/Hydration Pass.” A review of Patient 1’s record titled “Situation, Background, Assessment, Report (SBAR)” dated 9/25/2023, indicated “It was reported by Patient 3 that on Saturday (9/23/2023) [Patient 1] was seen pulling his private area out of his pants, and after he pulled it out, he touched the breast of Patient 2.” A review of Patient 2’s Admission Record indicated the facility admitted the 90 year old female patient, on 2/22/2023, with diagnoses that included unspecified dementia with behavioral disturbances and Alzheimer’s disease. A review of Patient 2’s HPE signed and dated by the attending physician on 2/23/2023, indicated the patient did not have the capacity to understand or make decisions. A review of Patient 2’s MDS dated 8/31/2023, indicated the patient had severely impaired cognition (thought process). The MDS indicated Patient 2 required extensive assistance (patient involved in activity; staff provide weight bearing support) with bed mobility, transferring between surfaces, walking in room, dressing, toilet use and personal hygiene. The MDS indicated Patient 2 required supervision limited assistance (patient highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) while eating. A review of Patient 2’s SBAR form dated 9/25/2023, indicated a narrative note, “It was reported by Patient 3 that on Saturday (9/23/23) Patient 1 was seen pulling out his private part out and after he pulled it out he touched Patient 2’s breast. Patient 3 stated that she notified [Family (FM) 1] who went to notify the Receptionist.” A review of Patient 3’s Admission Record indicated the facility admitted the 67 year old female patient, on 2/18/2022, with diagnoses that included hypertension (when your blood pressure, the force of blood flowing through your blood vessels, is consistently high) secondary to other renal disorders. A review of Patient 3’s HPE signed and dated by the attending physician on 2/01/2023, indicated the patient did not have the capacity to understand or make decisions. A review of Patient 3’s MDS dated 8/29/2023, indicated Patient 3 was cognitively intact. The MDS indicated Patient 3 required extensive assistance (patient involved in activity; staff provide weight bearing support) with bed mobility, transferring between surfaces, dressing and personal hygiene. The MDS indicated Patient 3 required supervision limited assistance (patient highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) while eating. During an interview with Patient 2 on 9/26/2023 at 11 AM, Patient 2 stated she remembered a patient touching her “heart” on Saturday 9/23/2023. During an interview with Patient 3 on 9/26/2023 at 12:15 PM, Patient 3 stated on Saturday 9/23/2023 around 2 PM, while in the facility’s Activity Room, she observed Patient 1 wheeling self-closer to Patient 2. Patient 3 stated she saw Patient 1 take out his penis from his pants and place his finger over his mouth as in “signaling” to Patient 2 to stay quiet. Patient 3 stated she observed Patient 1 touched his penis and then proceed to touch Patient 2’s breast. Patient 3 stated she observed Patient 2 sitting on her wheelchair looking at Patient 1 without reaction while Patient 1 was touching Patient 2’s breasts. Patient 3 stated that she screamed at Patient 1 to stop but Patient 1 did not because he was hard of hearing. Patient 3 stated she immediately informed Family Member 1 (FM1), who was in the Activity Room with another patient during that time the incident was happening. Patient 3 stated that FM 1 went outside the Activity Room to inform the facility’s Receptionist (RCP). Patient 3 stated she observed RCP coming into the Activity Room and wheeled Patient 1 out of the Activity Room. Patient 3 stated during the time of the incident, there were no facility staff members present and supervising in the Activity Room. During an interview with the Director of Nurses (DON) on 9/26/2023 at 12:50 PM, the DON stated Patient 3 informed her of the incident of sexual abuse between Patient 1 and Patient 2 on 9/25/2023 (2 days after the incident). The DON stated none of the facility staff informed her or the Administrator of the sexual abuse allegation that happened between Patients 1 and 2 on 9/23/2023. During an interview with the RCP on 9/26/2023 at 1:30 PM, the RCP stated that on 9/23/2023 she was notified by Patient 3 that Patient 1 had his penis out and was touching Patient 2’s breast. The RCP stated FM 1 informed her of Patient 3’s claims as well. The RCP stated she informed the Activities Assistant who wheeled Patient 1 out of the Activities Room on 9/23/2023. The RCP stated she only informed the Activities Assistant and maybe Certified Nursing Assistant (CNA) 1. The RCP stated she could not recall what she informed CNA 1. The RCP stated she did not inform anyone else of the alleged sexual abuse allegations reported to her by Patient 3. During an interview with FM 1 on 9/26/2023 at 2:29 PM, FM 1 stated she was in the facility’s Activity Room visiting with another patient family member on 9/23/2023 at around 2 PM. FM 1 stated Patient 3 notified her that Patient 1 had his penis out and was touching Patient 2’s breast. FM 1 stated she yelled at Patient 1 to stop it and immediately went to notify the RCP who was outside the Activity Room. FM 1 stated there was no staff present in the Activity Room when the sexual abuse incident happened between Patients 1 and 2. During an interview with CNA 1 on 9/26/2023 at 3:32 PM, CNA 1 stated she was outside Patient 1’s room on Saturday of 9/23/2023 when the RCP and the Activities Assistant where observed wheeling Patient 1 back to his room. CNA 1 stated the Activities Assistant notified her to put Patient 1 back to bed because “He was trying to touch someone.” CNA 1 stated she thought Patient 1 was trying to grab or hit someone as he had a history of getting aggressive with staff. CNA 1 stated she was not informed of the sexual abuse that happened between Patient 1 and Patient 2. CNA 1 stated if she had been informed, she would have reported it immediately to the charge nurse. During an interview with the Activity Director on 9/26/2023 at 4:30 P.M., the AD stated that the activity staff was expected to be present in the Activity Room when patients are present. The AD stated patients should never be left alone unsupervised in the Activity Room because there are vulnerable patients that always need supervision/assistance. The AD stated that on 9/23/2023 at 2 PM, there was an activity scheduled for the patients (juice/hydration pass) in the Activity Room and a facility staff should had been present to oversee patients. A review of the facility’s policy and procedure titled “Abuse Prevention Program” dated 5/28/2019, indicated “Our patients have the right to be free from abuse... The policy indicated, “This includes sexual or physical abuse…” The policy further indicated the facility will protect patients from abuse by anyone including, other patients. The facility failed to ensure Patient 2 was free from sexual abuse (non-consensual sexual contact) on 9/22/2023 around 2 PM when Patient 1 exposed his penis (the male genital organ) and grabbed Patient 2’s breast while in the facility’s Activity Room as observed by Patient 3. These deficient practices resulted in Patient 2 experiencing sexual abuse and unwanted nonconsensual sexual contact from Patient 1. Patient 2, who has a diagnosis of Alzheimer’s (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) did not exhibit a change in behavior due to the sexual abuse but had a potential to suffer a negative psychosocial outcome such as anger, fear, anxiety, or loss of self-esteem using the reasonable person concept (assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the patient’s position). The above violation had a direct or immediate relationship to the health, safety or security of Patient 2.