Other·November 23, 2022

§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. §483.12(a) The facility must— §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 22 CCR §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. On 10/12/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident about resident-to-resident abuse. The facility's Activity Assistant (AA) failed to ensure Resident 1 was free from abuse when Resident 2 punched Resident 1 on 10/7/2022 at 9:30 a.m. in the Activities Room. The AA was in the Activities Room and saw Resident 1 bumped his wheelchair into Resident 2, Resident 2 screamed, and Resident 2 turned his wheelchair and hit Resident 1's chest. As a result, Resident 1 experienced soreness on his left chest wall on the pacemaker insertion site and was given a pain medication. A review of Resident 1's Admission Record indicated the facility admitted a 62-year-old male resident on 8/16/2022, with diagnoses including chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), muscle weakness, and bradycardia (slow heart rate). A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 8/23/2022, indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) for daily decision making was intact. The MDS indicated Resident 1 required limited assistance with one-person physical assist with locomotion on (how resident moves between locations in his/her room and adjacent corridor on same floor; if in wheelchair self-sufficiency once in chair) and locomotion off unit (how resident moves and returns from off -unit locations; if in wheelchair self-sufficiency once in chair). A review of Resident 1's History and Physical (H&P), dated 8/23/2022, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 2's Admission Record indicated the facility admitted a 72-year-old resident on 2/8/2021, with diagnoses including cerebral infarction (blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), acute respiratory failure, and aphasia (language disorder caused by damage in a specific area of the brain that controls language expression and comprehension following cerebral infarction. A review of Resident 2's MDS, dated 2/16/2022, indicated Resident 2's cognitive skills for daily decision making was moderately impaired. The MDS indicated the resident required supervision with one-person physical assist with locomotion on and locomotion off unit. A review of Resident 2's H&P, dated 2/2/2022, indicated Resident 2 was alert and dysarthric (slurred speech). A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR-a communication tool that allows health professionals to communicate clear elements of a resident's condition) Communication for Changes in Condition (COC), dated 10/7/2022, indicated Resident 1 received physical aggression from another resident. The SBAR indicated Resident 1 was punched on his left chest wall, pacemaker (a small electronic device that is placed in the chest to help regulate slow electrical problems with the heart) insertion site. A review of the Investigation of the Incident, dated 10/10/2022 and updated on 10/13/2022, indicated that on 10/7/2022 at 9:30 a.m., Resident 1 accidentally bumped his wheelchair into the back of Resident's wheelchair in the activities room. Both residents exchanged words. Resident 2 proceeded to hit Resident 1 three in the upper chest. Both residents were immediately separated by the Activities Assistant (AA); body checks were completed by nurse; the Sheriff department, Ombudsman and the Department of Health were notified. A review of the facility's investigation conclusion, dated 10/10/2022 and updated on 10/13/2022, indicated the facility substantiated that a physical altercation took place on 10/7/2022 between Resident 1 and Resident 2. A review of the AA's written statement, dated 10/7/2022, indicated the AA observed Resident 1 ran into Resident 2's wheelchair and Resident 2 screamed. The statement indicated the AA was making coffee and stated to Resident 1 to stay away from Resident 2. The statement indicated Resident 1 "runs over again" Resident 2's wheelchair; Resident 2 turned his wheelchair, lifted his hand and hit Resident 1's chest three times; the AA ran and pulled Resident 1's wheelchair. During a concurrent observation and interview on 10/12/2022 at 9:30 a.m., observed Resident 1 in his wheelchair. Resident 1 stated he accidentally bumped into Resident 2's wheelchair and Resident 2 punched him in the upper left chest. The resident stated a pacemaker was recently placed on the area where he got punched (resident pointed to his upper left chest). The resident stated the site was sore, and the nurse gave him pain medication. A review of the Medication Administration Record for the month of 10/2022, indicated that on 10/7/22, Resident 1 received Acetaminophen tablet 325 milligram (mg), two tablets by mouth every 4 hours as needed for pain level of 3 (using 0 to 10 scale, 3 is mild pain) at 12:10 p.m. During a concurrent observation and interview on 10/12/2022 at 10:03 a.m., observed Resident 2 in his wheelchair. Resident 2 was asked if he punched Resident 1, Resident 2 stated, "yes." During an interview on 10/12/2022 at 9:51 a.m., the Activity Director (AD) stated the AS reported to her that Resident 1 bumped his wheelchair onto Resident 2 twice. Resident 2 got upset after Resident 1 bumped onto his wheelchair the second time. The AS separated both residents after Resident 2 punched Resident 1 in the chest. During a telephone interview on 10/12/2022 at 10:13 a.m., the Activity Assistant (AA) stated that she observed Resident 1 bumped his wheelchair onto Resident 2's wheelchair. The AA stated Resident 2 started screaming and she told Resident 1 not to run onto Resident 2's wheelchair. The AA stated Resident 1 kept bumping his wheelchair onto Resident 2's wheelchair. The AA stated she observed Resident 2 hit Resident 1 three times in the chest. The AA stated Resident 1 screamed, "You hit my pacemaker, you hit my pacemaker." The AA stated she separated both residents and reported the incident to the AD. During a follow-up interview on 10/12/2022 at 12:06 p.m., the AD stated the AA could have assisted Resident 1 when the resident was having difficulty with his wheelchair. During an interview on 10/12/2022 at 12:29 a.m., the Administrator (ADM) stated that the video from the camera in the activities room showed Resident 1 bumping his wheelchair onto Resident 2's wheelchair. Resident 1 tried to move around and bumped his wheelchair onto Resident 2's wheelchair. Resident 2 turned around; there was an exchange of words and Resident 2 hit Resident 1 on the chest. The Activity Assistant (AA) separated the residents as soon as she saw the altercation. A review of the facility’s policy titled, "Abuse Prevention and Prohibition Program," revised on 6/1/2021, indicated each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property; the facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, friends, and visitors. The facility's AA failed to ensure Resident 1 was free from abuse when Resident 2 punched Resident 1 on 10/7/2022 at 9:30 a.m. in the Activities Room. The AA was in the Activities Room and saw Resident 1 bumped his wheelchair into Resident 2, Resident 2 screamed, and Resident 2 turned his wheelchair and hit Resident 1's chest. As a result, Resident 1 experienced soreness on his left chest wall on the pacemaker insertion site and was given a pain medication. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.