Health inspection·December 19, 2024

F600 §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 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. 22 CCR 72315. Nursing Service – Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. On 10/31/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a Facility-Reported Incident (FRI) regarding resident abuse. The facility failed to protect Resident 4’s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) when on 10/17/2024 at around lunch time, Registered Nurse 2 (RN 2) witnessed Resident 5 punched Resident 4 with his (Resident 5) closed fist twice on the right side of face while Resident 4 was sitting on the wheelchair. As a result, Resident 4 was subjected to physical abuse by Resident 5 while under the care of the facility. Based on the Reasonable Person Concept (the usual behavior of an average person under the same circumstances), due to Resident 4’s severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and medical condition, an individual subjected to physical abuse may have physical pain, psychological pain (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation, and humiliation (the feeling of being ashamed or losing respect for own self). A review of Resident 4's Admission Record indicated the facility admitted Resident 4 on 12/6/2022 with diagnoses that included hemiplegia (total or partial paralysis [loss of the ability to move] of one side of the body) and hemiparesis (one-side muscle weakness) following cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area) affecting right dominant side and dysphagia (difficulty swallowing) following cerebral infarction. A review of Resident 4's Minimum Data Set (MDS – a resident assessment tool) dated 8/16/2024 indicated Resident 4 had severely impaired cognition. The MDS also indicated Resident 4 required partial or moderate assistance (helper does less than half the effort) with eating, and is dependent with oral hygiene, toileting hygiene, and personal hygiene. A review of Resident 4’s Change in Condition (COC- a significant change in resident’s health status) Evaluation, dated 10/17/2024, timed at 4:36 p.m. indicated the resident (Resident 4) received punch from another resident (Resident 5) while sitting in wheelchair. A review of Resident 5’s Admission Record indicated Resident 5 was originally admitted to the facility on 2/15/2024 and re-admitted on 7/16/2024 with diagnoses that included schizophrenia (a mental illness that affects a person’s thoughts, feelings, and behaviors), unspecified mood disorder (a mental health condition that primarily affects a person’s emotional state), and personal history of traumatic brain injury (a brain injury caused by an external force such as a blow, jolt or impact to the head). A review of Resident 5's MDS dated 10/30/2024 indicated Resident 5 had severely impaired cognition. The MDS also indicated Resident 5 required partial/moderate assistance with eating and oral hygiene, dependent with toileting hygiene, and required substantial/maximal assistance (helper does more than half the effort) with personal hygiene. A review of Resident 5’s Physician Orders dated 10/17/2024, timed at 7:12 p.m. indicated to transfer Resident 5 to General Acute Care Hospital 1 (GACH 1) due to physical aggression (behavior directed toward another person that results in physical harm or has the potential to cause physical harm) towards the other Resident. During an interview on 11/4/2024 at 11:41 a.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated that on 10/17/2024 around lunch time, he (CNA 3) was washing his hands in station 4. CNA 3 heard Resident 5 yell and when he (CNA 3) turned around, CNA 3 witnessed Resident 5 punched Resident 4 with his (Resident 5’s) closed fist twice on the right side of Resident 4’s face. During an interview on 11/4/2024 at 3:45 p.m., with RN 2, RN 2 stated that on 10/17/2024 at around lunch time, RN 2 witnessed Resident 5 punched Resident 4. RN 2 stated that RN 2 was at station 4 at around lunch time RN 2 witnessed Resident 4 being wheeled next to Resident 5, Resident 5 reached over and pulled Resident 4’s wheelchair close to Resident 5 and punched Resident 4 with a closed fist twice in the face. During an interview on 11/5/2024 at 10:51 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she (LVN 2) was assigned to Resident 5 on 10/17/2024. LVN 2 stated that on 10/17/2024 at around lunch time, LVN 2 witnessed Resident 5 punched Resident 4 with his (Resident 5’s) closed fist twice on the right side of Resident 4’s face. During a follow-up interview on 11/5/2024 at 11:00 a.m., with LVN 2, LVN 2 stated that physical abuse did occur because Resident 5 was witnessed punching Resident 4 in the face. During an interview on 11/5/2024 at 1:48 p.m., with the Social Services Director (SSD), when asked if the incident (Resident 5 punched Resident 4 in the face on 10/17/2024) between Resident 4 and Resident 5 was physical abuse, the SSD stated that he (SSD) did not feel comfortable answering the question. The SSD stated that Resident 5 had history of aggressive behavior and that the facility should have been more proactive in monitoring Resident 5’s behavior to ensure other residents were not within range for Resident 5 to punch or hit. A review of the facility’s policy and procedure titled, “Abuse, Neglect (fail to care properly), and Exploitation (taking advantage of a resident)”, last reviewed in 9/25/2024, indicated “it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect….” The facility failed to protect Resident 4’s right to be free from physical abuse when on 10/17/2024 at around lunch time, RN 2 witnessed Resident 5 punched Resident 4 with his (Resident 5) closed fist twice on the right side of face while Resident 4 was sitting on the wheelchair. As a result, Resident 4 was subjected to physical abuse by Resident 5 while under the care of the facility. Based on the Reasonable Person Concept, due to Resident 4’s severely impaired cognition and medical condition, an individual subjected to physical abuse may have physical pain, psychological pain effects including feelings of hopelessness, helplessness, and humiliation. The above violation had direct or immediate relationship to the health, safety, or security of Resident 4.