Health inspection·December 29, 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 §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. 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 11/15/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate facility-reported incidents (FRIs) about resident-to-resident abuse. The facility failed to ensure Resident 1 and Resident 3 had the right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) when: 1. On 11/1/2023, Resident 2 punched Resident 1 in the stomach. 2. On 11/11/2023, Resident 4 punched Resident 3 in the face. As a result, Resident 1 and Resident 2 were subjected to physical abuse while under the care of the facility. Resident 3 sustained a bloody nose. Based on the reasonable person concept due to Resident 1’s severely impaired cognition (ability to think and make decisions) and Resident 3’s moderately impaired cognition, an individual subjected to physical abuse has lifetime physical pain and psychological effects including feelings of embarrassment and humiliation. 1. A review of Resident 1’s Admission Record, indicated Resident 1 was originally admitted to the facility on 3/20/2023 with a diagnosis of Alzheimer’s disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out simple tasks). A review of Resident 1’s Minimum Data Set (MDS- a standardized assessment and screening tool), dated 8/15/2023, indicated Resident 1 sometimes understood others and could be understood. A review of Resident 1’s Situation-Background-Assessment-Recommendation Communication Form (SBAR, a form that provides communication between health care team members about a resident 's condition) dated 11/1/2023, and timed at 11:32 a.m., indicated that on 11/1/2023 at around 10:45 a.m., Certified Nurse Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1) immediately separated Resident 1 and Resident 2, and that Resident 1 had stated that Resident 2 had hit Resident 1 in the stomach. A review of Resident 2’s Admission Record, indicated Resident 2 was originally admitted to the facility on 8/12/2023 then readmitted on 10/26/2023 with diagnoses that included schizoaffective disorder (mental illness that can affect your thoughts, mood, and behavior), and depression (persistent sadness or lack of interest). A review of Resident 2’s MDS dated 9/25/2023, indicated Resident 2 sometimes understood others and could be understood. A review of Resident 2’s SBAR Communication Form dated 11/1/2023 timed at 10:45 a.m. indicated that on 11/1/2023 at around 10:45 a.m., Resident 2 hit Resident 1 with a closed fist using her right hand in the abdominal area. The SBAR further indicated that Resident 2 stated she hit Resident 1 because Resident 1 was standing next to Resident 2. During an interview on 11/15/2023 at 9:45 a.m., Resident 1 stated that she was unable to recall the incident between Resident 2 that had occurred on 11/1/2023. During an interview on 11/15/2023 at 11:50 a.m., CNA 1 stated that on 11/1/2023, close to “lunch time,” CNA 1 saw Resident 2 sitting in her wheelchair near the nursing station. CNA 1 stated that Resident 1 walked over and stood next to Resident 2. CNA 1 stated she saw Resident 2 appear to be irritated and that Resident 2 suddenly reached out with her right hand in a closed fist and hit Resident 1 in stomach area with the backside of Resident 2’s fist. When asked how CNA 1 knew that Resident 2 was irritated, CNA 1 stated that she heard Resident 2 state “move, you’re too close to me” as she hit Resident 1. CNA 1 stated that the incident was not an accident and that Resident 2 looked irritated as she hit Resident 1. CNA 1 stated that she then saw Resident 1 holding her stomach with both hands immediately after being hit by Resident 2. During an interview on 11/15/2023 at 2:50 p.m., LVN 1 stated that on 11/1/2023 he was in the nursing station charting (documenting in medical records) when CNA 1 reported that Resident 2 had hit Resident 1. LVN 1 stated that according to Resident 2, Resident 2 hit Resident 1 because Resident 1 was next to Resident 2. During an interview on 11/15/2023 at 5:55 p.m., the Administrator (ADM) stated that as the facility’s abuse coordinator (designated to investigate abuse allegations) she investigated the incident that occurred on 11/1/2023 at approximately 10:45 a.m. between Resident 1 and Resident 2. ADM stated that Resident 1 was found to have been hit in the stomach by Resident 2 with a closed fist. When asked if Resident 1 was free from abuse while under the care of the facility, ADM stated no. 2. A review of Resident 3’s Admission Record, indicated Resident 3 was originally admitted to the facility on 6/8/2022 and readmitted on 3/20/2023 with diagnoses that included unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and schizoaffective disorder. A review of Resident 3’s MDS, dated 9/11/2023, indicated Resident 3 sometimes understood others and could be understood. A review of Resident 3’s SBAR Communication Form, dated 11/1/2023 timed at 7:15 p.m., indicated on 11/11/2023 at around 7:45 p.m. Resident 3 was found by CNA 3 having a fist fight with Resident 4. The SBAR Communication Form further indicated that because of the fist fight, Resident 3 sustained a bloody nose and torn shirt. A review of Resident 4’s Admission Record, indicated Resident 4 was originally admitted to the facility on 9/29/2023 with diagnoses that included schizoaffective disorder and anxiety (persistent and excessive worry that interferes with daily activities) disorder. A review of Resident 4’s MDS dated 10/4/2023, indicated Resident 4 had the ability to understand and be understood. A review of Resident 4’s SBAR Communication Form dated 11/11/2023 timed at 8:49 p.m., indicated that on 11/11/2023 at around 7:15 p.m. Resident 4 was found by CNA 3 having a fist fight with Resident 3. The form indicated that Local Law Enforcement were notified to investigate the incident. The form indicated that Resident 4 was then transferred to a General Acute Care Hospital (GACH) on 11/11/2023 at 11:00 p.m. for further evaluation. During an interview on 11/15/2023 at 10:10 a.m., Resident 3 stated that he was unable to recall the incident with Resident 4 that had occurred on 11/11/2023. During an interview on 11/15/2023 at 2:05 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that on 11/11/2023 at around 7:30 p.m., he saw Resident 3 and Resident 4 hitting each other. CNA 2 stated that he saw the two residents were both seated in their own wheelchairs and were both hitting each other with closed fists. CNA 2 stated that he saw Resident 3 with blood on the resident’s face at the time he separated Resident 3 and Resident 4. During an interview on 11/15/2023 at 2:29 p.m., CNA 3 stated that on 11/11/2023 around 7:00 p.m., CNA 3 observed Resident 3 and Resident 4 sitting in their own wheelchairs close by each other. CNA 3 stated that Resident 3 and Resident 4 were seen talking to each other at first, then both residents started to scream at one another. CNA 3 stated that as she tried to separate the two residents, Resident 3 and Resident 4 held onto each other’s wheelchairs. CNA 3 stated that she then saw Resident 4 hit Resident 3 first in the face. CNA 3 stated she was unable to recall if Resident 3 had hit Resident 4. CNA 3 stated that she saw Resident 3 bleeding from his nose. During an interview on 11/15/2023 at 3:05 p.m., LVN 2 stated that on 11/11/2023, LVN 2 was notified by CNA 3 of a fist fight between Resident 3 and Resident 4. LVN 2 stated that when she went and saw Resident 3, Resident 3 had blood dripping from both nostrils that covered the resident’s upper lip. LVN 2 stated that Resident 3 was observed with his shirt ripped apart on the right chest and shoulder area. During an interview on 11/15/2023 at 5:55 p.m., the ADM, ADM stated that as the facility’s abuse coordinator she investigated the incident between Resident 3 and Resident 4. ADM stated that Resident 3 and Resident 4 were in a physical altercation which resulted in Resident 3 having a bloody nose. When asked if Resident 3 was free from abuse while under the care of the facility, ADM stated no. A review of the facility’s policy and procedures (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 ensure Resident 1 and Resident 3 had the right to be free from physical abuse when: 1. On 11/1/2023, Resident 2 punched Resident 1 in the stomach. 2. On 11/11/2023, Resident 4 punched Resident 3 in the face. As a result, Residents 1 and 2 where subjected to physical abuse while under the care of the facility. Resident 3 sustained a bloody nose. Based on the reasonable person concept due to Resident 1’s severely impaired cognition and Resident 3’s moderately impaired cognition, an individual subjected to physical abuse has lifetime physical pain and effects including feelings of embarrassment and humiliation. The above violations had a direct relationship to the health, safety, or security of Resident 1 and Resident 3.