Health inspection·July 25, 2024

§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 6/20/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about an allegation of staff to resident verbal abuse. The facility failed to ensure the Facility Cook (FC) did not verbally abuse Resident 1 by yelling at Resident 1 to "shut up". As a result, Resident 1 felt humiliated and verbalized not feeling safe in the facility. Resident 1 was a 58-year-old male, admitted to the facility on 4/26/2024 with diagnoses including chronic obstructive pulmonary disease ([COPD]- a lung disease characterized by long term poor airflow), major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy), and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 1's Minimum Data Set ([MDS]- a standardized assessment and care-screening tool) dated 5/8/2024, indicated the resident's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. The MDS 'Mood' section indicated Resident 1 was feeling down, depressed, or hopeless during the lookback period (time frame for assessment). A review of Resident 1's Care Plan on behavior, dated 6/6/2024, indicated the resident had a behavior of throwing the dinner tray at the kitchen. The Care Plan intervention included to anticipate and meet Resident 1's needs. A review of Resident 1's Change of Condition (COC) form, dated 6/9/2024, indicated the resident went to the kitchen and spoke to the FC about the resident's diet slip (a list of foods served to the resident based on the resident's diet order). The COC form indicated facility staff separated the FC from Resident 1 when the FC started to argue with the resident. The COC form indicated Resident 1 felt safe if the FC was not there. The attending physician was notified at 2 p.m. on 6/9/2024. A review of Resident 1's Progress Notes dated 6/9/2024 timed at 2:27 p.m., indicated the Social Service Coordinator (SSC 1) heard a commotion outside the social service office. The Progress Notes indicated SSC 1 and the facility nursing staff stood in between the FC and Resident 1. A review of Resident 1's Progress Notes dated 6/9/2024 timed at 3:28 p.m., as a late entry, indicated SSC 1 was notified about the alleged verbal abuse between the FC and Resident 1. The Progress Notes indicated Resident 1 showed the diet slip to the FC to address some concerns the resident had on the food received. The Progress Notes indicated the FC stated he did not care for Resident 1, he did not respect the resident, and that the FC could read the diet slip. The Progress Notes indicated Resident 1 did not feel safe in the facility with the FC. The resident was informed that FC was no longer in the facility. A review of the facility provided Investigation Interviews, dated 6/9/2024, indicated the Admissions Coordinator (AC) witnessed the verbal altercation between the FC and Resident 1. The documented interview indicated the FC stated to AC that Resident 1 was rude, and he could not work with the resident anymore. The documented interview indicated that the altercation escalated, and the FC told Resident 1 to "shut up." A review of Resident 1's Psychiatric (related to the study of mental illness) Evaluation, dated 6/18/2024, indicated the resident had a history of bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) intermittent anger outbursts and bouts of poor judgment. The Psychiatric Evaluation 'Assessment Plan' section indicated Resident 1 to continue psychotropic medication regimen for psychiatric stabilization. On 6/20/2024 at 9:52 a.m., during an interview, Resident 1 stated the FC came out of the kitchen and spoke to the AC about Resident 1 while the resident was within hearing distance. Resident 1 stated that the FC was pointing his finger at him and stating in a loud voice that he does not like, and respect Resident 1 and he could not work with the resident. Resident 1 stated that the FC answered him in an arrogant tone when he asked the FC to read the diet slip. Resident 1 stated that the FC clenched his fist like he was going to hit him and yelled at him to "shut up." Resident 1 stated that the FC was a big man while he (Resident 1) on a wheelchair that required the use of an oxygen. Resident 1 stated that he felt humiliated and agitated by the FC's actions towards him. Resident 1 stated that he did not feel safe in the facility knowing that the FC could come back and hurt him. Resident 1 stated that he felt safe after the facility informed him that the FC was fired. On 6/20/2024 at 10:33 a.m., during an interview, the AC stated on 6/9/2024 at 1:30 p.m., the FC yelled at Resident 1 to "shut up." The AC stated on 6/9/2024 Resident 1 approached her for help with the diet slip. The AC stated both went to the kitchen. The FC started to talk to the AC about Resident 1, who was within hearing distance, while FC was pointing his finger at Resident 1. The AC stated the FC called Resident 1 rude and stated he could not work with the resident. The AC stated Resident 1 was calm, but the FC stated some harsh words which agitated the resident. The AC stated the FC's voice was loud and sounded irritated as he yelled at Resident 1 to "shut up." The AC stated there were facility staff and residents in the hallway during the incident. The AC stated she led the FC outside the facility and asked him to go home. On 6/20/2024 at 11:55 a.m., during an interview, SSC 1 stated she went out of her office because she heard a loud commotion. SSC 1 stated the FC and Resident 1 were cursing at each other at the hallway in front of the kitchen. The SSC 1 stated that Resident 1 was brought to the social service office to calm the resident down and to get the resident's statement about the incident. The SSC 1 stated Resident 1 did not feel safe with the FC in the facility. The SSC 1 stated she told Resident 1 that the FC was no longer in the facility. The SSC 1 defined abuse as an incident where a resident felt unsafe or there was a threat to the resident's safety whether verbal or physical in nature. The SSC 1 stated that the verbal altercation between the FC and Resident 2 was an abuse because the resident felt unsafe at that time. On 6/20/2024 at 2:46 p.m., during a concurrent interview and record review, the Administrator (ADM) stated he was the facility's abuse prevention coordinator. The facility-provided Investigation Interview report dated 6/9/2024, was reviewed with the ADM and the report indicated the FC stated to the AC that Resident 1 was rude, and FC could not work with the resident anymore. The report indicated the FC told Resident 1 to "shut up." The ADM stated the FC's behavior was inappropriate and did not cater to customer service and professionalism. The ADM stated that the incident had the potential for residents to be scared to bring up similar events in the future. The ADM stated that the facility failed to ensure the residents were treated with respect and free from potential abuse. A review of the facility's policy and procedure titled, "Abuse Prohibition and Prevention Program," dated 10/26/2023, indicated the purpose to provide staff guidelines to ensure protection for the health, welfare, and rights of each resident residing in the facility and to ensure the facility was doing all that is within its control to prevent occurrence of abuse. The Screening section of the policy indicated the facility check with the appropriate licensing board and registries prior to hire and annually thereafter. The Prevention section of the policy indicated the facility strived to provide an environment which prohibits and prevents abuse, neglect, and exploitation of residents through identification, correction, and intervention in situations in which abuse, neglect, and/or misappropriation of resident property was more likely to occur. A review of the facility's policy and procedure titled, "Resident Rights," dated 10/26/2023, indicated residents in long term care facilities have rights guaranteed to them under Federal and State law including the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The policy indicated employees shall treat residents with kindness, dignity, and respect. The facility failed to ensure the Facility Cook (FC) did not verbally abuse Resident 1 by yelling at Resident 1 to "shut up". As a result, Resident 1 felt humiliated and verbalized not feeling safe in the facility. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1.