Other·November 22, 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 10/12/2023, 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 Resident 1’s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) inflicted by Resident 2, who on 9/23/2023 at 7:25 a.m., hit and scratched Resident 1 on the face. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained a skin tear (a wound that happens when the layers of skin separate or peel back) on the left cheek of his face and redness (red discoloration to the skin) on right cheek of his face, left cheek of his face, and left lower jaw. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 1’s severely impaired cognition (mental action or process of acquiring knowledge and understanding), an individual subjected to physical abuse may have long-lasting physical pain and psychological (mental or emotional) effects including feelings of embarrassment and humiliation. A review of Resident 1’s Admission Record, indicated Resident 1 was originally admitted to the facility on 2/10/2023 and readmitted on 7/21/2023 with a diagnosis of chronic kidney disease (the gradual loss of kidney function). A review of Resident 1’s Minimum Data Set (MDS- a standardized assessment and screening tool), dated 8/16/2023, indicated Resident 1 had severely impaired cognition and required total assistance from staff with activities of daily living such as bed mobility, transfers, eating, toilet use, personal hygiene, and bathing. A review of Resident 1’s Situation – Background – Assessment – Recommendation (SBAR) Communication Form (a form used to facilitate prompt communication regarding a change in a resident’s health condition), dated 9/23/2023 timed at 9:50 a.m., indicated on 9/23/2023 at around 7:25 a.m. Certified Nurse Assistant 1 (CNA 1) found Resident 1 being hit and scratched by Resident 2. The SBAR further indicated that Resident 1 was noted with open skin and active bleeding on the face requiring pressure to be applied to the open skin to stop the bleeding. A review of Resident 1’s Wound Assessment Report dated 9/23/2023, indicated Resident 1 sustained a skin tear on the left cheek with a length of 1.0 centimeters (cm- a unit of measurement) and a width of 1.0 cm, edges are not well approximated (not a clear cut edge on the skin) with presence of torn skin flaps (skin removed from area of the face), and redness on the left cheek measuring 2.0 cm by 3.0 cm. Further review of the Wound Assessment Report dated 9/23/2023, indicated that upon assessment of Resident 1’s right cheek, the resident sustained redness measuring 2.5 cm by 3.5 cm and redness measuring 0.5 cm by 0.2 cm to the left lower jaw. A review of Resident 1’s Physician Order dated 9/23/2023 indicated to apply steri-strips (thin adhesive bandages or strips of tape applied across a cut to keep the edges of the wound together as it heals) on the left cheek until it falls off and to monitor for any signs and symptoms of infection. Further review of Resident 1’s Physician Order dated 9/23/2023 indicated to monitor Resident 1’s right cheek, left cheek and left lower jaw for discoloration (change in natural skin color) and for adverse reaction such as pain, discomfort, or further skin breakdown daily for 30 days. A review of Resident 2’s Admission Record, indicated Resident 2 was originally admitted to the facility on 3/10/2023 then readmitted on 6/25/2023 with diagnoses that included hydrocephalus (a brain disorder with too much fluid built up inside the brain that causes pressure on the brain’s tissues), generalized anxiety (feeling of worry, nervousness, or unease) disorder and mood disorder. A review of Resident 2’s MDS dated 6/16/2023, indicated Resident 2 had moderately impaired cognition. A review of Resident 2’s SBAR Communication Form dated 9/23/2023 timed at 8:09 a.m. indicated on 9/23/2023 at around 7:25 a.m. Resident 2 went inside Resident 1’s room and started hitting and scratching Resident 1. The SBAR Communication Form further indicated Resident 2 was observed with disruptive behavior (any behavior or conduct that interferes with safe resident care) by hitting, grabbing, scratching, and threatening Resident 1. A review of Resident 3’s Admission Record, indicated Resident 3 was originally admitted to the facility on 5/30/2022 then readmitted on 10/19/2022 with a diagnosis of Parkinson’s Disease (a brain disorder that causes unintended or uncontrollable movements such as shaking). A review of Resident 3’s MDS dated 7/3/2023, indicated Resident 3 had intact cognition. During an interview on 10/12/2023 at 2:20 p.m. with Resident 3, Resident 3 stated that on 9/23/2023, unable to recall the time, Resident 3 witnessed the physical altercation (a dispute between two residents in which one sustain bodily injury as a result) between Resident 1 and Resident 2. Resident 3 stated that he shares a room with Resident 1. Resident 3 stated he was in his bed when he saw Resident 2 standing on the right side of Resident 1 as Resident 1 was lying in bed. Resident 3 stated that he saw Resident 2 then hit Resident 1 with what appeared to be a rolled-up towel. Resident 3 stated that he then saw Resident 2 with both hands clenched into a fist. Resident 3 stated he witnessed Resident 2 repeatedly hit Resident 1’s face. Resident 3 stated that he then saw Resident 1 bleeding from the face. Resident 3 stated it appeared as if Resident 1 was unable to defend himself as he was being attacked by Resident 2. During an interview on 10/12/2023 at 3:15 p.m. with Resident 2, Resident 2 was unable to recall the incident with Resident 1 on 9/23/2023. During an interview on 10/12/2023 at 6:30 p.m. with CNA 1, CNA 1 stated that on 9/23/2023 at around 7:25 a.m., CNA 1 heard Resident 3 calling CNA 1’s name to his room stating that someone was fighting in the room (referring to Resident 1 and Resident 3’s room). CNA 1 stated she ran in to the room to find Resident 2 standing on the right side of Resident 1. CNA 1 stated she saw Resident 2 had his left hand on Resident 1’s bed for support while using his (Resident 2) right hand in a closed fist to hit Resident 1 on the face. CNA 1 stated she told Resident 2 to stop and had to hold him back. CNA 1 stated she saw Resident 1 bleeding from the face. During an interview on 10/13/2023 at 3:05 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that on 9/23/2023 at around 7:25 a.m., LVN 2 heard CNA 1 screamed from Resident 1’s room. LVN 2 stated that she ran over and saw CNA 1 redirecting Resident 2 away from Resident 1’s room. LVN 2 stated that Resident 1’s left cheek had open skin and was bleeding from the face. LVN 2 stated that after tending to the residents she reported the incident immediately to the Director of Nursing (DON) that Resident 2 was found physically abusing Resident 1. LVN 2 further stated Resident 1 was later transferred to a General Acute Care Hospital 1 (GACH 1) not related to the incident with Resident 2. During an interview on 10/13/2023 at 5:10 p.m. with the Administrator (ADM), the ADM stated that she is the abuse coordinator (the person that investigates allegations of abuse in the facility). ADM stated she was notified by the DON regarding the incident between Resident 1 and Resident 2 that occurred on 9/23/2023. ADM stated that her investigation of the incident between Resident 1 and Resident 2 was physical abuse, with Resident 1 having sustained physical injuries. A review of the facility’s policy and procedure (P&P) titled, “Abuse Investigation and Reporting,” dated 2/2023, indicated that it is the right of the resident to be free from abuse. A review of the facility’s P&P titled, “Abuse Prevention,” undated, indicated the facility does not condone any form of resident abuse. Physical Abuse is defined as hitting, slapping, pinching, and/or kicking. The P&P further indicated that the facility would promote an environment free from abuse and mistreatment. The facility failed to protect Resident 1’s right to be free from physical abuse inflicted by Resident 2, who on 9/23/2023 at 7:25 a.m., hit and scratched Resident 1 on the face. As a result, Resident 1 was subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained a skin tear on the left cheek of his face and redness on right cheek of his face, left cheek of his face, and left lower jaw. Based on the reasonable person concept due to Resident 1’s severely impaired cognition, an individual subjected to physical abuse may have long-lasting physical pain and psychological effects including feelings of embarrassment and humiliation. The above violations had a direct relationship to the health, safety, or security of Resident 1.