Other·February 24, 2022

F604 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §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. §483.12(a) The facility must- §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

F 609 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, Title 22 § 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. § 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. § 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: (9) To be free from mental and physical abuse. On 10/20/2021, the California Department of Public Health made an unannounced visit to the facility to conduct a facility-reported incident and complaint investigation about Resident 1’s restraints and abuse. The facility failed to ensure Resident 1 was free from abuse and neglect, had the right to be treated with dignity and respect, and was free from unnecessary restraints per facility’s policies and procedures. On 10/7/2021, the facility was made aware the transportation driver was tying Resident 1 down the wheelchair during the transportation from and to a treatment center but continued to allow the transportation of Resident 1 without a staff accompanying the resident on 10/9/2021 and 10/12/2021. The facility did not: 1. Protect Resident 1 from further abuse and unnecessary restraining measures by the transportation driver, 2. Conduct a thorough investigation of the allegation received on 10/7/2021, 3. Report to the alleged abuse to the necessary agencies. As a result, Resident 1 was subjected to further use of restraints to control Resident 1's behavior and causing the resident undetermined psychological trauma, mental anguish, and fear that a resident with impaired cognition may not express outward (reasonable person standard). A review of Resident 1's Admission Record indicated the facility admitted the resident a 59-year-old male, on 6/1/2021 and re-admitted him on 10/6/2021 with diagnoses including osteomyelitis (infection of the bone), schizophrenia (disorder affecting ability to think and behave), type 2 diabetes mellitus (refers to a group of diseases that affect how your body uses blood sugar [glucose]), seizure disorder (a central nervous system [neurological] disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness), end stage renal disease (ESRD - is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) on hemodialysis (is a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean your blood), hypertension (a condition in which the force of the blood against the artery walls is too high), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations. Fast heart rate, rapid breathing, sweating, and feeling tired may occur), bipolar disorder (is a brain disorder that causes changes in a person's mood, energy, and ability to function), general muscle weakness, heart failure (disease condition where heart muscle is unable to pump blood adequately) and pneumonia (infection of one or both lungs). A review of Resident 1's Care Plan developed on 6/18/2021, indicated Resident 1 and/or responsible party were made aware the facility had stabled systems to prevent abuse. Resident 1 shall not be subject to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies, family members of legal counsel. The interventions included - Inform Resident 1 and/or responsible party of the facility policy for reporting abuse (concern form) to be completed by Resident 1, their appointed representative or staff members of the facility. Abuse included unreasonable confinement. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/14/2021, indicated Resident 1 had moderately impaired cognition (is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday). Resident 1 needed extensive assistant with most activity of daily living (ADLs - such as bed mobility, transfer, dressing, personal hygiene, and toilet use). Resident 1 used a walker and wheelchair as mobility devices. Resident 1 was incontinent of bladder and bowel functions (inability of the body to control the evacuative functions of urination or defecation). A review of Resident 1's Care Plan developed on 9/25/2021 for the resident's problem of Non-Compliance with Care by Refusing Medication, included in the interventions providing explanation or rationale of care for better compliance, informing the resident of possible alternatives, consequences / needs, and notifying the resident of any risks / consequence of non-compliance. A review of the Physician's Orders for Resident 1, on re-admission 10/6/2021, indicated to have hemodialysis treatment at a dialysis center three times a week on Tuesdays, Thursdays, and Saturdays at 8:10 a.m. Pick up by transportation van at 7:30 a.m. A review of a Grievance Report form dated 10/7/2021, completed by Social Services 1 (SS 1) and signed by the Administrator, indicated Resident 1 came back from the dialysis center with a blanket tied around his body/waist. The transportation company confirmed the driver had to tie Resident 1 with a blanket because Resident 1 was refusing to sit down and was combative. SS 1 documented a sitter (companion) would be provided to Resident 1 for future appointments including dialysis treatment to ensure his safety." A review of the Physician's Orders for Resident 1, dated 10/7/2021, indicated to administer the resident Ativan 0.5 milligrams (mg) one tablet by mouth twice a day for inability to cope with ADLs causing anger. A review of Resident 1's Care Plan developed on 10/7/2021 for the resident's problem of Non-Compliance Behavior to Prescribed Medical Treatment - Refusing Hemodialysis, included in the interventions providing explanation or rationale of therapy / care for better compliance and discussing benefits of compliance with and risks of non-compliance. A review of Resident 1's History and Physical exam completed by the attending physician on 10/8/2021, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Care Plan developed on 10/12/2021 for the resident having periods of anxiety manifested by inability to cope with ADL's causing anger, included in the interventions keeping Resident 1 away from stressful situations. A review of Resident 1's Licensed Nurse Record dated 10/12/2021 timed at 4:06 a.m., signed by Licensed Vocational Nurse 2 (LVN 2), indicated Resident 1 left at 7 a.m., with the transportation driver. A review of Resident 1's Care Plan developed on 10/12/2021, for the resident having periods of anxiety manifested by inability to cope with ADL's causing anger included in the interventions keeping Resident 1 away from stressful situations. A review of Resident 1's Change of Condition (COC) documentation, dated 10/12/2021, indicated the resident had generalized rash and blisters, identified at the dialysis center and present upon the resident's return to the facility. Resident went to General Acute Care Hospital 1 (GACH 1) for evaluation of possible allergic reaction. A review of Resident 1's Admission Notes dated 10/17/2021, indicated the resident returned from GACH 1. A review of Resident 1's Change of Condition (COC) documentation, dated 11/1/2021 timed at 1:55 p.m., indicated the Administrator received a report on 10/7/2021 about Resident 1 been tied down while transported to the hemodialysis center. At 2:20 p.m., Resident 1's body assessment noted no injury. This body assessment was done 11/1/2021, 25 days after the report dated 10/7/2021. A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR - communication form used to facilitate prompt and appropriate communication about a resident's condition) dated 11/1/2021, indicated at 2:20 p.m., the Ombudsman (advocate for the rights of long-term care facilities residents) called the Administrator about Resident 1 being tied down while transporting him from and to the dialysis center. Resident 1 got aggressive, screamed, and spat at a staff when he was being interviewed by a staff about the incident. Resident 1 was re-assessed for body injury about the incident, facility noted no injury on Resident 1. Facility notified Resident 1's physician, the State Survey Agency (SSA) and law enforcement. On 10/20/2021 at 10:05 a.m., during an interview, Hemodialysis Staff 1 (HDS 1) stated on 10/9/2021 and 10/12/2021 Resident 1 was dropped off at the dialysis center tied up to his wheelchair because according to the driver, Resident 1 was combative and would not sit down. HDS 1 stated the facility did not send a companion (sitter) with Resident 1 to hemodialysis. On 11/16/2021 at 9:47 a.m., during an interview with SS 1 and a concurrent review of the Grievance Report form dated 10/7/2021, SS 1 stated Resident 1 returned from hemodialysis on that day (10/7/2021) with a blanket tied around his waist. SS 1 stated the transportation company was called and was told Resident 1 was tied with a blanket because he was refusing to sit down. The facility's corrective action was to provide a sitter for future appointments including hemodialysis transfer to ensure safety of the resident. SS 1 stated the investigation was documented in the grievance report, informed the Administrator, who signed the report. On 11/16/2021 at 10:37 a.m., during an interview, Nursing Aide 1 (NA 1) stated being assigned since 11/2/2021 to accompany Resident 1 to appointments including hemodialysis. NA 1 did not accompany Resident 1 on 10/9/2021 and 10/12/2021. NA 1 stated Resident 1 went to the dialysis center alone (no staff accompanying him) with the transportation driver until 11/2/2021. On 11/17/2021 at 12:26 p.m., during an interview, SS 1 confirmed writing a Grievance Report on Resident 1's abuse allegation, SS 1 stated the abuse coordinator was the Administrator and he would report the abuse to the necessary agencies. SS 1 stated the driver's action constituted abuse of Resident 1. On 11/17/2021 at 2:37 p.m., during an interview, Director of Nursing (DON) after reviewing Resident 1's clinical record, confirmed the licensed nurses did not notify Resident 1's physician about abuse incident in a timely manner. DON stated there was no physician's order for the use of restraint for Resident 1. Using a restraint without the necessary assessment and physician's order was a type of physical abuse. DON stated after the grievance on 10/7/2021, the decision was to provide a sitter when going to hemodialysis appointment. DON confirmed Resident 1 left for dialysis on 10/9/2021 and 10/12/2021 without a sitter. DON stated sitter should have been provided to prevent the driver from tying the resident. DON stated physical restraint can cause skin breakdown, emotional trauma, and behavioral issues. DON stated the facility was responsible for protecting residents from any form of abuse. On 11/17/2021 at 3:59 p.m., during an interview, the Administrator confirmed he was the facility's Abuse Coordinator and learned about the abuse allegation during the stand-up meeting on 10/7/2021. Administrator stated Resident 1 was supposed to be provided with a sitter to dialysis to protect him from further abuse. On 1/23/2022 at 2:35 p.m., during an interview, Registered Nurse 3 (RN 3) stated on 10/7/2021 a dialysis center staff called to inform her Resident 1 had been combative during the hemodialysis. RN 3 stated she called the physician and obtained an order for lorazepam when Resident 1 arrived at the facility with anger issues. RN 3 stated Resident 1 was not on lorazepam on readmission on 10/06/2021 but exhibited behavior issues on 10/7/2021 upon return from hemodialysis. A review of facility's contract agreement with the dialysis services dated 11/4/2004, indicated the facility had the responsibility for arranging suitable transportation of the patient including the qualified personnel to accompany the patient. The facility shall be responsible for ensuring that the patient is medically stable to undergo such transportation and shall be responsible for the patient during the transfer. A review of facility's undated policy and procedures titled, "Abuse & Mistreatment of Residents" indicated the purpose was to uphold a resident's right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion. Administrator shall be responsible for reporting of all alleged and substantiated violations to the state agency and all other agencies as required. Facility shall report the incident by notifying the California Department of Public Health (CDPH or SSA) within two hours of the knowledge of such incident. Facility shall make reasonable efforts to protect residents from harm during an investigation process, when incidents involving the health, welfare, to safety of residents are reported, involved resident(s) shall be removed from the environment that threatens resident's health, welfare, or safety. Facility shall ensure complete and thorough investigation is conducted for all allegations of abuse. A review of facility's policy and procedures titled, "Physical Restraint" last reviewed on 11/23/2021, indicated physical restraint are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot move easily and which restrict the freedom of movement or normal access to the use of one's bod