Other·November 27, 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 10/17/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a Facility-Reported Incident (FRI) about resident abuse. The facility failed to protect and ensure Resident 1 and Resident 2 had the right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another). On 10/1/2023, at 7:30 p.m., Resident 1 hit Resident 2 in the head with a trashcan lid, and Resident 2 hit Resident 1 in the head with a wooden back scratcher. As a result, Resident 1 and Resident 2 were subjected to physical abuse while under the care of the facility, and both residents required transfer to a General Acute Care Hospital (GACH) for possible head injuries. A review of Resident 1’s Admission Record indicated the facility admitted the resident on 11/9/2022 and readmitted on 8/12/2023 with diagnoses including depression (persistent sadness) 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-planning tool) dated 8/19/2023 indicated Resident 1 was able to remember, communicate, and make decisions. The MDS further indicated that Resident 1 needed extensive assistance from staff with bed mobility and transfer and needed supervision with locomotion (movement from one place to another). A review of Resident 1’s Change in Condition (CIC - when there is a sudden change from a resident’s health) Evaluation Form dated 10/1/2023, indicated that on 10/1/2023, at approximately 7:30 p.m., staff (unidentified) heard screaming at the staff and resident’s lounge. The CIC Evaluation Form indicated Resident 1 was hit by Resident 2 and was noted with a small lesion (wound) with red discoloration (redness) to the left side of the head. The CIC Evaluation Form indicated that Resident 1 then hit Resident 2 and as a result, Resident 2 sustained red discoloration to the forehead. Resident 1’s physician ordered to transfer the resident to a GACH for a Computed Tomography (CT - a diagnostic imaging procedure that uses a combination of X-ray [a photographic or digital image of a part of the body] and computer technology to produce images of the inside of the body) of the brain. A review of Resident 1’s head CT result dated 10/2/2023 done at the GACH indicated, the reason for the examination was for dizziness due to blunt trauma (injury of the body by forceful impact with a dull object). A review of Resident 1 Physician’s Order indicated an order dated 10/2/2023 for treatment for Resident 1’s scrape (skin injury) to the left front temporal area (left side of the head) by cleansing the site with Normal Saline (NS - solution composed of salt and water), pat dry, apply antibiotic ointment (medication that are applied on skin to help kill bacteria) and to leave the injury open to air daily for 10 days. A review of Resident 1’s Skin Assessment Form dated 10/2/2023, indicated, Resident 1 was involved in a resident-to-resident physical altercation that resulted with Resident 1 sustaining a scrape measuring one (1) centimeter (cm) in length, and one (1) cm in width to Resident 1’s left side of the forehead with discoloration (change in natural skin color) measuring at seven (7) cm in length and three (3) cm in width. A review of Resident 2’s Admission Record indicated the facility admitted the resident on 6/10/2021 and readmitted on 10/27/2022 with diagnoses including neuropathy (when nerve damage leads to pain, weakness, numbness or tingling in one or more parts of your body). A review of Resident 2’s MDS dated 9/13/2023 indicated Resident 2 was able to remember, communicate, and make decisions. The MDS further indicated that Resident 2 needed extensive assistance from staff with bed mobility and transfer and needed limited assistance from staff with locomotion. A review of Resident 2’s CIC Evaluation Form dated 10/1/2023, indicated, at 7:30 p.m., at approximately 7:30 p.m., facility staff (unidentified) heard a screaming at the staff and resident’s lounge. The CIC Evaluation Form indicated that Resident 2 had a physical altercation with Resident 1 and was noted with red discoloration to the forehead. The CIC Evaluation Form further indicated that Resident 2’s physician ordered for the resident to be transferred to a GACH for a CT of the head. A review of Resident 2’s CT of the head result dated 10/2/2023 done at the GACH indicated, the reason for examination was trauma. A review of Resident 2’s GACH Discharge Instructions Form dated 10/2/2023, indicated, Resident 2’s discharge diagnosis was closed head injury (occur when there is a non-penetrating injury to the brain with no break in the skull [the bony framework of the head]). A review of Resident 2’s Skin Assessment Form dated 10/2/2023, indicated, Resident 2 was involved in a resident-to-resident physical altercation resulting in Resident 2 sustaining a bruise (an injury appearing as an area of discolored skin on the body) measuring five (5) cm in length and four (4) cm in width to Resident 2’s left hand as a result of blocking the physical assault (intentionally causing or attempting to cause physical harm to another through force or violence) from Resident 1 on 10/1/2023. A review of Resident 3’s Admission Record indicated the facility admitted the resident on 12/30/2022 with diagnoses that included diabetes mellitus (the body’s inability to control the amount of sugar in the blood). A review of Resident 3’s MDS dated 10/9/2023 indicated Resident 3 was able to remember, communicate, and make decisions. The MDS further indicated that Resident 3 needed supervision with locomotion. On 10/17/2023 at 12:36 p.m., during an interview, Resident 2 stated that on 10/1/2023 (unable to recall exact time) while playing a card game with Resident 1 and Resident 3, Resident 1 became angry and was not following the rules of the game. Resident 2 stated that with his wooden back scratcher, Resident 2 gestured to Resident 1 as if he was about to hit Resident 1 with the wooden back scratcher. Resident 2 stated he was unsure if he hit Resident 1 with the wooden back scratcher at that time. Resident 2 then stated that Resident 1 picked up the lid of a nearby trash can and attempted to hit Resident 2 in the head. Resident 2 stated that he used his left arm to block Resident 1’s attack. Resident 2 stated that as a result of blocking Resident 1’s attack, he sustained a bruise to his left hand. Resident 2 stated that Resident 1 attempted to strike Resident 2’s head multiple times, but that Resident 2’s head was “okay”. Resident 2 stated that in his angry state, he used his wooden back scratcher to then hit Resident 1 in the head. Resident 2 stated that Resident 3 was there the entire time and witnessed the altercation. During an interview with Resident 3 on 10/17/2023 at 12:55 p.m., Resident 3 stated that on 10/1/2023 at around 7:30 p.m., he was playing a card game with Resident 1 and Resident 2. He stated that Resident 1 did not agree to one of the rules of the card game being led by Resident 2 at the time. Resident 3 stated that Resident 1 informed Resident 2 that he was no longer going to play the card game, at which point Resident 2 attempted to hit Resident 1 with his back scratcher. Resident 3 stated he then witnessed Resident 1 pick up the lid of a trash can and hit Resident 2 in the head. Resident 3 stated everything happened “so quickly,” and then he suddenly noticed that Resident 1 was bleeding from the head. Resident 3 stated that facility staff arrived soon after and separated Resident 1 and Resident 2. During an interview with Resident 1 on 10/17/2023 at 2:30 p.m., Resident 1 stated that about two weeks ago (10/1/2023), at around 7:30 p.m., while playing a card game with Resident 2 and Resident 3, Resident 2 hit his head with a wooden back scratcher three to four times. Resident 1 stated that he began bleeding from his head and was sent to a hospital for a CT of the brain. During an interview with the Director of Nursing (DON) on 10/17/2023 at 5:10 p.m., DON stated, the facility was aware about the on-going card games being played by Resident 1, Resident 2, and Resident 3. The DON stated that Resident 1, Resident 2, and Resident 3 were all alert and had intact cognition (ability to think and make decisions). When the DON was asked if the incident where in Resident 1 and Resident 2 both hit one another in the head multiple times would be considered physical abuse, the DON stated that there is always a possibility of a resident-to-resident altercation to occur because the residents could “lose control” as a result of the games being played. The DON stated that facility staff intervened and both Resident 1 and Resident 2 were separated after the “physical contact.” A review of the facility’s policy and procedure (P&P) titled, “Abuse & Mistreatment of Residents”, reviewed on 7/27/2021, indicated, “To uphold a resident’s right to be free from verbal, sexual, and mental abuse, corporal punishment (physical punishment), and involuntary seclusion.” The policy defined abuse as the willful (intentional) infliction of injury.” The facility failed to protect and ensure Resident 1 and Resident 2 had the right to be free from physical abuse. On 10/1/2023, at 7:30 p.m., Resident 1 hit Resident 2 in the head with a trashcan lid, and Resident 2 hit Resident 1 in the head with a wooden back scratcher. As a result, Resident 1 and Resident 2 were subjected to physical abuse while under the care of the facility, and both residents required transfer to a GACH for possible head injuries. The above violations had a direct relationship to the health, safety, or security of Resident 1 and Resident 2.