Other·October 21, 2022

§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. §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. §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. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 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 9/12/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint regarding employee to resident abuse. The facility failed the following: 1. To provide an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used as indicted in the facility's policy for Resident 1 by failing to ensure a top sheet covering the resident was not tied to a bed rail (metal or plastic bars positioned along the side of a bed). 2. To report the allegation of staff-to-resident abuse no later than two hours from after the allegation was made and provide the results of facility investigation within five working days to the State Survey Agency (SSA) for Resident 1. The allegation of abuse was reported by staff (LVN 1 and CNA 2) to the Director of Nursing (DON) on 9/1/2022. The facility reported the allegation on 9/15/2022. The facility failed to submit the 5-day investigation report on 9/8/2022. 3. To complete a thorough investigation of an allegation of staff-to-resident abuse for Resident 1. As a result, these had the potential to violate Resident 1’s right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms and had the potential to result in serious physical harm from entrapment. These also had the potential to result in unidentified abuse in the facility and failure to protect other residents from abuse. A review of Resident 1's Admission Record indicated the facility admitted the resident on 9/4/2019, with diagnoses including epilepsy (a group of disorders marked by problems in the normal functioning of the brain that can produce seizures, unusual body movements, a loss of consciousness as well as mental problems or problems with the senses), osteoporosis (a disease that thins and weakens the bones), and Alzheimer ' s disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/8/2022, indicated the resident was severely impaired in cognition (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills for daily decision making, and was totally dependent on staff on most areas of activities of daily living (ADLs, such as dressing, eating and personal hygiene). During a telephone interview on 9/12/2022 at 1:38 p.m. Certified Nursing Assistant 1 (CNA 1) stated that she tied the top sheet that was covering Resident 1 to a strap attached to the sheepskin (a synthetic, soft, high-pile pads and provide rail protection) on the right bed rails on 9/1/2022 between 5 a.m. to 5:35 a.m. because the resident was exposing herself by kicking the sheet off the bed. CNA 1 stated she gave a written statement to the DON on 9/2/2022. CNA 1 stated that she was not suspended during the investigation. A review of CNA 1's written statement of the alleged incident on 9/12/2022 indicated that Resident 1 was restless and kept kicking the covers off. CNA 1 stated she tied one corner of the top sheet to prevent the top sheet from falling. During an interview on 9/12/2022 at 2:08 p.m., and concurrent record review of the Certified Nursing Assistant 2’s (CNA 2’s) written statement of the alleged incident provided by the DON, CNA 2 stated she found Resident 1 on bed covered with a top sheet tied to the bed rail and the resident was "stuck," when CNA 2 attempted to sit the Resident 1 upright. CNA 2's written statement indicated that she saw the top sheet was tied to the bed rail (metal or plastic bars positioned along the side of a bed). CNA 2 reported the incident to the Director of Nursing (DON) on 9/1/2022 and gave a written statement on 9/2/2022. During a concurrent telephone interview and record review on 9/12/2022 at 3:38 p.m. Licensed Vocational Nurse 2 (LVN 2) documentation on the nurse's notes was reviewed. LVN 2’s documentation indicated Resident 1's top sheet was tied in a knot to the white strap on the right side which was restraining the resident's body from properly sitting up. LVN 2 stated that Resident 1's top sheet was tied in a knot to the sheepskin's strap on the right bed rail. LVN 2 stated that the top sheet was covering the resident's body, slanted over the resident's right shoulder preventing the resident from sitting up. LVN 2 wrote her statement on the nurse's notes dated 9/1/2022 at 8 a.m. LVN 2 stated that DON informed her that statements from the other staff will be taken up during the investigation. During an interview on 9/12/2022 at 4:30 p.m., the Director of Nursing (DON) stated she obtained statements from staff regarding Resident 1's top sheet that was tied to a bed rail. The DON stated she conducted a "quasi" (apparently but not really) investigation of the alleged incident, but she determined that it did not rise to the level of abuse because the sheet did not restrain the resident's movement. During an interview on 9/13/2022 at 9:38 a.m., the DON stated LVN 2 and CNA 2 informed her on 9/1/2022 about the top sheet being tied to Resident 1's bed rails but she determined it was not a restraint because it did not restrict the resident's movement. The DON stated she did not assess the resident because she did not observe the resident's top sheet tied to the bed rail. The DON also stated that she did not read the statements of the staff (CNA 1, CNA 2, and LVN 1) written on 9/2/2022 and LVN 2's documentation of the alleged incident in Resident 1's nurse's notes on 9/1/2022. The DON stated that she did not report the alleged abuse to the SSA, Ombudsman and law enforcement because Resident 1 was not harmed, and the top sheet did not restrain the resident from moving. The DON stated the alleged abuse should be reported within 2 hours. The DON stated that she has not submitted the results of the investigation because based on her investigation abuse did not take place and so there is nothing to report. The DON also stated she did not notify Resident 1's physician and responsible party of the alleged incident. DON stated she did not conduct a thorough investigation of the alleged abuse incident. A review of the facility's policy and procedure titled, "Resident Behavior and Facility Practices - Physical and Chemical Restraints," dated 7/1/2019 and reviewed on 9/9/2021, indicated the facility will ensure that the resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, not required to treat the resident ' s medical symptoms, and to unnecessarily inhibit a resident ' s freedom of movement or activity. A review of the facility's policy and procedure titled, "Abuse, Neglect and Exploitation Prevention," dated 8/11/2020 and reviewed on 9/9/2021, indicated that the facility will report allegations involving abuse (physical, verbal, sexual or mental) not later than two hours after the allegation is made and report the findings of all completed investigations within five (5) working days to the Department of Health. The policy also indicated that the employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation and all reports of suspected abuse must also be reported to the family and attending physician. The facility failed the following: 1. To provide an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used as indicted in the facility's policy for Resident 1 by failing to ensure a top sheet covering the resident was not tied to a bed rail (metal or plastic bars positioned along the side of a bed). 2. To report the allegation of staff-to-resident abuse no later than two hours from after the allegation was made and provide the results of facility investigation within five working days to the State Survey Agency (SSA) for Resident 1. The allegation of abuse was reported by staff (LVN 1 and CNA 2) to the Director of Nursing (DON) on 9/1/2022. The facility reported the allegation on 9/15/2022. The facility failed to submit the 5-day investigation report on 9/8/2022. 3. To complete a thorough investigation of an allegation of staff-to-resident abuse for Resident 1. As a result, these had the potential to violate Resident 1’s right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms and had the potential to result in serious physical harm from entrapment. These also had the potential to result in unidentified abuse in the facility and failure to protect other residents from abuse. The above violations had direct or immediate relationship to the health, safety, or security of Resident 1.