Health inspection·June 8, 2023

42 CFR § 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. 22 CCR § 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: (10) To be free from mental and physical abuse. On 5/1/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about resident-to-resident abuse. The facility failed to protect the right of Resident 1 and Resident 2 to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) as indicated in the facility’s policy on Abuse Reporting and Prevention when on 4/28/2023, at 12:00 p.m., Resident 2 threw a water pitcher container at Resident 1 (his roommate), hitting Resident 1 on the left eyebrow and Resident 1 in return threw his cane at Resident 2, hitting Resident 2’s forehead. As a result, Resident 1 sustained a laceration (a deep cut or tear in the skin) on the left eyebrow requiring transfer to General Acute Care Hospital 1 (GACH 1) for sutures (a stitch or a row of stitches holding together the edges of a wound). Resident 2 sustained skin tears (wound that happens when the layers of skin separate) to the mid-forehead and skin tears to the left eyebrow. A review of Resident 1’s Admission Record indicated the facility admitted the resident, an 86-year-old male, on 4/17/2023 with diagnoses including syncope (fainting or passing out) and collapse, history of falling, and fracture (broken bone) of nasal bones (bones located in the nose). A review of Resident 1’s History and Physical exam, dated 4/18/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 4/24/2023, indicated Resident 1 had the ability to make himself understood and to understand others, had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and required limited one-person assistance from staff for bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, and eating. A review of Resident 1’s Situation-Background-Assessment-Recommendation (SBAR) Communication Form (a tool used to facilitate prompt communication regarding a change in a resident’s health condition), dated 4/28/2023, indicated that Resident 1 was involved in a resident-to-resident physical altercation on 4/28/2023. The SBAR indicated that on 4/28/2023 at approximately 12:00 p.m., the case manager witnessed Resident 1 throw his cane at Resident 2 after Resident 2 had thrown a pitcher at Resident 1’s head. The SBAR indicated Resident 1 was then noted with a laceration to his left eyebrow. A review of the Physician’s Orders for Resident 1, dated 4/28/2023, indicated to transfer Resident 1 to GACH 1 for a left eyebrow laceration needing sutures. A review of GACH 1’s Summary (of care) for Resident 1, dated 4/28/2023, indicated Resident 1 was seen at GACH 1 for a head injury and left eyebrow laceration, which was repaired with sutures. Resident 1 was sent back to the facility the same day. A review of Resident 1’s Skin and Body Assessment, dated 4/28/2023 at 8:00 p.m., after the resident’s return to the facility indicated Resident 1 had a left eyebrow laceration with sutures. A review of Resident 2’s Admission Record indicated the facility admitted the resident, a 75-year-old male, on 4/1/2023 with diagnoses including metabolic encephalopathy (ME - occurs when problems with the metabolism [the chemical changes that take place in a cell or an organism] cause brain dysfunction; causes range from low blood sugar to excess fluid in the brain; symptoms range from confusion, irritability to coma [inability consistently to follow a one-step command]; prompt treatment is essential) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). A review of Resident 2’s History and Physical Exam, dated 4/3/2023, indicated the resident can make his needs known but cannot make medical decisions. A review of Resident 2’s MDS, dated 4/7/2023, indicated the resident had the ability to make himself understood and to understand others, had severely impaired cognition, and required extensive one-person assistance from staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. A review of Resident 2’s SBAR Communication Form, dated 4/28/2023, indicated after Resident 1’s cane hit Resident 2, Resident 2 sustained skin tears to the mid-forehead and left eyebrow. On 5/1/2023 at 3:05 p.m., during a concurrent observation and interview, Resident 1 was sitting on a chair at his bedside reading a book. Resident 1 had a dark red laceration with sutures on the left eyebrow. When Resident 1 was asked if he was able to recall the incident with Resident 2 on 4/28/2023, Resident 1 stated no. Resident 1 then stated that he did not want to answer any further questions. On 5/1/2023 at 3:34 p.m., during an interview, Case Manager 1 (CM 1) stated that on 4/28/2023 at around 12:00 p.m., he was passing by the nurses’ station when he heard yelling coming from Residents 1 and 2’s room. CM 1 stated he saw Resident 2 throw a water pitcher at Resident 1 and in response, Resident 1 threw his cane at Resident 2’s head. CM 1 stated he immediately separated the two residents. On 5/1/2023 at 4:44 p.m., during an interview, the Administrator (ADM) stated that he was the facility’s abuse coordinator and the incident on 4/28/2023 between Residents 1 and 2 could be considered deliberate physical abuse since both residents threw things (cane and water pitcher) at each other. A review of the facility’s policy and procedure titled, “Abuse Reporting and Prevention,” last reviewed on 1/2023, indicated that a resident-to-resident altercation should be reviewed as a potential situation of abuse. The policy further stated that if the resident’s actions were “willful” or deliberate then abuse has occurred. The policy indicated that “Abuse” means the willful infliction of injury. The policy indicated that physical abuse is a willful physical action that is meant to inflict physical harm, pain, or mental anguish. The facility failed to protect the right of Resident 1 and Resident 2 to be free from physical abuse as indicated in the facility’s policy on Abuse Reporting and Prevention when on 4/28/2023, at 12:00 p.m., Resident 2 threw a water pitcher container at Resident 1 (his roommate), hitting Resident 1 on the left eyebrow and Resident 1 in return threw his cane at Resident 2, hitting Resident 2’s forehead. As a result, Resident 1 sustained a laceration on the left eyebrow requiring transfer to GACH 1 for sutures. Resident 2 sustained skin tears to the mid-forehead and skin tears to the left eyebrow. The above violations had a direct relationship to the health, safety, and security of Resident 1 and Resident 2.