Health inspection·September 9, 2022

42CFR §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 §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. (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. On 6/17/2022, the California Department of Public Health made an unannounced visit to the facility to investigate a facility-reported incident about resident-to-resident abuse. The facility failed to ensure Resident 1 was free from physical abuse inflicted by Resident 2. On 6/5/22 around 1:53 p.m., Resident 2 was sitting in her wheelchair outside her room when Resident 1 pushed Resident 2’s wheelchair and then, Resident 2 responded by hitting with the hand Resident 1’s left side of the face. Licensed Vocational Nurse 1 (LVN 1) witnessed the incident and prevented Resident 2 from further attempt to hit Resident 1. As a result, Resident 1 sustained a red left cheek. Based on the reasonable person concept, due to Resident 1’s severely impaired cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) and medical condition, an individual subjected to physical abuse, may have pain and psychological effects including feelings of hopelessness, helplessness, and humiliation. A review of Resident 1's Admission Record indicated the facility admitted the resident on 10/7/21 with diagnoses including dementia (memory disorders, personality changes, and impaired reasoning that interferes with daily functioning) and major depressive disorder (a mood disorder characterized by a persistent feeling of sadness and loss of interest). A review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 5/9/22, indicated Resident 1’s cognition was severely impaired. Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering) with transfer, walking in room, locomotion on unit (how resident moves between locations in her room and adjacent corridor on same floor) with one-person physical assistance. Resident 1 was not steady and only able to stabilize with staff with walking and turning around. A review of Resident 1’s SBAR (Situation, Background, Assessment, and Recommendation, a technique to standardize communication within the health care team) Communication Form and Progress, dated 6/5/22 at 1:53 p.m., indicated Resident 2 struck Resident 1 on the face resulting on a discoloration on Resident 1’s left upper cheek. A review of the Physician's Order for Resident 1 dated 6/5/22, indicated to monitor the left upper cheek discoloration if increased or open affected areas for 14 days. A review of Resident 2’s Admission Record indicated the facility originally admitted the resident on 6/10/21 with last readmission dated on 4/23/22 with diagnoses including dementia with behavioral disturbance and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). A review of Resident 2’s MDS dated 4/26/22, indicated the resident’s cognition was severely impaired. Resident 2 was able to walk with one-person physical assistance. Resident 2 was not steady and was only able to stabilize with staff assistance. A review of Resident 2’s Health Status Note, dated 6/5/22 at 1:53 p.m., indicated on 6/5/22 at 1:53 p.m. Resident 2 was witnessed hitting with the hand Resident 1 on the face while in the hallway… Resident 2 stated she struck Resident 1 because Resident 1 was pushing her wheelchair. During an interview on 6/17/22 at 1:35 p.m., the Licensed Vocational Nurse 1 (LVN 1) stated she was the charge nurse who responded to the incident between Residents 1 and 2 on 6/5/22. LVN 1 stated she was standing by her cart and preparing medications to administer when she heard Resident 1 screamed and was covering her face. Resident 1 was standing on Resident 2’s right side and tried to hit Resident 1 again. LVN 1 stated she did not recall if Resident 1 hit Resident 2 with her opened hand or with a closes fist. LVN 1 stated after the incident Resident 1 sustained redness on her left side of her face and applied cold compress. LVN 1 stated Resident 2 gets easily annoyed and when she asked what happened, Resident 2 told her that she did not want anybody touching her wheelchair. LVN 1 stated Resident 2 was on her wheelchair when it happened and gets around the facility on her wheelchair. During an interview on 6/27/22 at 1:49 p.m., CNA 2 stated she was one of the staff that responded to the incidents between Resident 1 and Resident 2 on 6/5/22. CNA 2 stated she was documenting on the wall screen when she heard a “slap” sound but did not see Resident 2 hitting Resident 1. CNA 2 stated Resident 1 screamed and covering her face and she went to separate them immediately. CNA 2 stated she did not understand what Resident 1 was saying and escorted her back to her room. CNA 2 stated she is familiar with Resident 2’s care. CNA 2 stated when Resident 2 tells you what she needs help with and sometimes she says foul words towards staff. A review of the facility’s policy and procedure titled, “Abuse Prevention and Prohibition Program,” reviewed and approved on 6/1/21, indicated it was the facility’s policy that each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property.” …Prevention: resident assessments and care planning are performed to monitor resident needs and address behaviors that may lead to conflict. The facility failed to ensure Resident 1 was free from physical abuse inflicted by Resident 2. On 6/5/22 around 1:53 p.m., Resident 2 was sitting in her wheelchair outside her room when Resident 1 pushed Resident 2’s wheelchair and then, Resident 2 responded by hitting with the hand Resident 1’s left side of the face. LVN 1 witnessed the incident and prevented Resident 2 from further attempt to hit Resident 1. As a result, Resident 1 sustained a red left cheek. Based on the reasonable person concept, due to Resident 1’s severely impaired cognition and medical condition, an individual subjected to physical abuse, may have pain and psychological effects including feelings of hopelessness, helplessness, and humiliation. The above violations had a direct relationship to the health, safety, and security of Resident 1.