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 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 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 11/4/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual Recertification Survey and investigate a Facility-Reported Incident (FRI) regarding resident abuse. The facility failed to protect Resident 33’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 11/3/2024 at 7:00 a.m., Resident 47 (roommate) threw a cup at Resident 33 hitting Resident 33's forehead. As a result, Resident 33 was subjected to physical abuse by Resident 47 while under the care of the facility. Resident 33 sustained a laceration (a deep cut or tear in the skin) on the forehead and required transfer to General Acute Care Hospital 1 (GACH 1). Resident 33 received sutures (a stitch or a row of stitches holding together the edges of a wound). Based on the Reasonable Person Concept (the usual behavior of an average person under the same circumstances), due to Resident 33'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 33’s Face Sheet (admission record) indicated the facility admitted Resident 33 on 10/06/2023 with diagnoses including dementia (a progressive state of decline in mental abilities) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). A review of Resident 33's Minimum Data Set (MDS - a resident assessment tool), dated 10/10/2024, indicated Resident 33 had severely impaired cognition. The MDS indicated Resident 33 was dependent (helper does all the effort; resident does none of the effort to complete the activity) on staff with dressing, toileting, and personal hygiene. A review of Resident 33's Situation, Background, Assessment, Recommendation Report (SBAR- a form used to facilitate prompt communication regarding a change in a resident's health condition), dated 11/3/2024, indicated on 11/3/2024 at 7:00 a.m., Resident 33's roommate (Resident 47) acted aggressively towards Resident 33, hit the resident (Resident 33) with a plastic cup which caused Resident 33 to sustain a laceration measuring four (4) centimeters (cm, a unit of measure in length). The SBAR indicated a Certified Nursing Assistant (CNA [CNA 4]) found Resident 33 bleeding on his face. The SBAR indicated 911 (emergency number used to request emergency assistance) was called due to the laceration continuously bleeding, paramedics (a person who is trained to give medical help in emergency situations) came at 7:18 a.m. and took over the care. A review of Resident 33's Nursing Progress Notes, dated 11/3/2024, indicated on 11/3/2024 at 7:18 a.m., the paramedics came and took over Resident 33's care. The Nursing Progress Note indicated the paramedics took Resident 33 to GACH 1 for further evaluation. A review of Resident 33's GACH 1 Emergency Room Discharge Summary, dated 11/3/2024, indicated Resident 33 received treatment for a four cm forehead laceration between the eyes, which was repaired with sutures. A review of Resident 33's Nursing Progress Notes dated 11/3/2024 at 2:05 p.m., indicated Resident 33 returned from GACH 1 with six stitches on the mid (middle area) forehead. A review of Resident 33's Physician's Orders, dated 11/3/2024, indicated an order to cleanse the mid forehead laceration with sutures with normal saline (a salty solution used for cleaning wounds), pat dry, paint with betadine (used to reduce the risk of infection), and cover with a dry dressing (a dressing that absorbs moisture from a wound), everyday shift for 14 days. A review of Resident 33's Care Plan (CP) for Abuse, created 11/03/2024 indicated Resident 33 received physical aggression (any behavior which involves attacking another person with the intent of harming) from the roommate. The care plan indicated a goal that Resident 33 will not have any negative outcomes related to the altercation through the next review. The care plan indicated interventions including informing local law enforcement, notifying the physician, and for nursing department to monitor for signs of emotional distress (a general term for a range of negative emotional reactions that can result from a stressful event or situation). A review of Resident 47's Face Sheet indicated the facility admitted Resident 47 on 8/28/2024 and re-admitted on 10/02/2024 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 47's MDS, dated 10/29/2024, indicated Resident 47 had intact cognition. The MDS indicated Resident 47 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying as resident completes an activity) with oral hygiene, dressing, and wheeling self in wheelchair. A review of Resident 47's SBAR, dated 11/3/2024, indicated Resident 47 initiated physical aggression towards another resident. The SBAR indicated Resident 47 complained the roommate (Resident 33) repeatedly called him the N-word, which upset him and verbalized (told) throwing the plastic cup at the roommate (Resident 33). The SBAR indicated when Resident 47 was asked if he is aware that the roommate is bleeding because of the laceration Resident 33 sustained from his (Resident 47's) action; Resident 47 stated, "I don't care, nobody can call me the N-word." A review of Resident 47's Social Services Progress Note, dated 11/4/2024, indicated the Social Services Director (SSD) spoke with Resident 47 regarding the incident on 11/3/2024 with his old roommate (Resident 33). The Social Services Progress Note indicated that Resident 47 stated that he (Resident 47) threw his empty coffee cup at his roommate (Resident 33) because he (Resident 33) repeatedly called him (Resident 47) the N-word and he (Resident 47) felt insulted, so he threw the cup at him (Resident 33). A review of Resident 47’s CP for Physical Aggression created 11/3/2024, indicated Resident 47 will not have any negative outcomes related to altercation through next review date. The Care Plan indicated interventions to provide one-to-one (when one staff is assigned to monitor one resident at all times) monitoring by a CNA. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 11/05/2024 at 8:23 a.m., LVN 3 stated she (LVN 3) went to the room of Resident 33 and Resident 47 on 11/3/2024 at approximately 7:00 a.m. at the start of the 7:00 a.m. to 3:00 p.m. shift. LVN 3 stated Resident 33 was bleeding continuously to the mid-forehead despite the application of a pressure dressing (a bandage that applies pressure to a wound to help it heal). LVN 3 stated Resident 47 was in the room and stated, "he (Resident 33) kept calling me the N-word, so I hit him with a cup." LVN 3 stated 911 was called, the paramedics arrived and took Resident 33 to the GACH 1. LVN 3 stated Resident 47 was moved to a different room from Resident 33. LVN 3 stated Resident 33 returned from GACH 1 at approximately 2:30 p.m. with sutures in his forehead. LVN 3 stated this incident is being treated as physical abuse and that a CNA is monitoring Resident 47, at all times. During an interview with Resident 47 on 11/05/2024 at 11:20 a.m., Resident 47 stated he hit Resident 33 with a coffee cup because he (Resident 33) called him the N-word. Resident 47 stated police came to the facility and stated he (Resident 47) had every right to do what he did. During an interview with the Director of Nursing (DON) on 11/07/2024 at 9:19 a.m., the DON stated the physical abuse allegation was substantiated (to show something to be true, or to support a claim with facts) because Resident 47 stated he hit Resident 33 because he became offended when Resident 33 called him the N-word. The DON stated it is important to keep residents safe from abuse to protect the residents and keep them from injury. During an interview with the Administrator (ADM) on 11/07/2024 at 1:59 p.m., the ADM stated the abuse allegation was substantiated because Resident 47 acted willfully (done intentionally, or on purpose) when he threw the cup at Resident 33. A review of the facility's policy and procedure (P&P) titled, "Abuse Prevention and Prohibition Program," last reviewed on 10/29/2024, indicated the residents have the right to be free from mistreatment, neglect (fail to care for properly), abuse .... The policy and procedure indicated facility staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, misappropriation (unauthorized, improper, or unlawful use) of resident property, or deprivation of goods necessary to attain or maintain physical, mental, and psychosocial well-being. The facility failed to protect Resident 33’s right to be free from physical abuse when on 11/3/2024 at 7:00 a.m., Resident 47 (roommate) threw a cup at Resident 33 hitting Resident 33's forehead. As a result, Resident 33 was subjected to physical abuse by Resident 47 while under the care of the facility. Resident 33 sustained a laceration on the forehead and required transfer to GACH 1. Resident 33 received sutures. Based on the Reasonable Person Concept, due to Resident 33'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 violations had direct or immediate relationship to the health, safety, or security of Resident 33.