Other·October 13, 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. §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. On 9/22/2023, 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 provide supervision for Resident 1 and Resident 2, who were assessed with agitation and aggressive behavior, to prevent a physical altercation. On 9/12/2023 at 5:35 p.m., in the TV room in the presence of five facility staff, none of the five staff members present in the TV room responded to stop the physical altercation between Resident 1 and Resident 2. As result, Residents 1 and 2 sustained skin tears (wounds caused by shear [cut], friction, and/or blunt force resulting in separation of skin layers) from the physical altercation. A review of Resident 1’s Admission Record indicated the facility admitted the resident on 2/3/2023 with diagnoses including atrial fibrillation (an abnormal heartbeat caused by extremely fast and irregular beats from the upper chambers of the heart), depression (a constant feeling of sadness and loss of interest which stops a person from doing normal activities), and essential hypertension (abnormal blood pressure that was not a result of a medical condition). A review of Resident 1’s undated History and Physical exam indicated the resident had agitation and did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 2/10/2023, indicated the resident’s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired. Resident 1 required extensive assistance (resident involved in activity and staff provided guided maneuvering) with one-person physical assist in bed mobility, transfer, locomotion on and off unit (how resident moves between locations in the room, adjacent corridor, and returns from off-unit locations), dressing, eating, toilet use, and personal hygiene. The functional limitation in range of motion section of the MDS indicated that Resident 1 had impairment on one side of the upper extremity (shoulder, elbow, wrist, hand). A review of Resident 1’s Care Plan on self-care deficits and extensive assistance, initiated on 8/14/2023, indicated an intervention to provide a safe environment, maintain resident’s privacy and respect resident rights. A review of Resident 1’s Care Plans indicated there were no care plans created for the resident’s agitation. A review of Resident 1’s Change of Condition / Interact Assessment Form, dated 9/12/2023, indicated that at 5:45 p.m., Certified Nursing Assistant (CNA) informed the licensed nurse that Resident 1 had an altercation with another resident. Resident 1 sustained a four centimeter (cm – unit of measurement) by four cm skin tear on the right hand with scant bleeding. On 9/12/2023 at 6:30 p.m., Resident 1’s physician and responsible party were notified. A review of Resident 1’s Physician Orders, dated 9/13/2023, indicated a right back hand skin avulsion (tearing away of a body part accidentally) to cleanse with normal saline (a mixture of water and salt solution), pat dry, and apply steri-strips (an adhesive strip used to secure, close, and support cuts, wounds, and surgical incisions) and keep steri-strips for 7 days. A review of Resident 2’s Admission Record indicated the facility admitted the resident on 1/3/2022 and readmitted on 6/23/2023 with diagnoses including unspecified psychosis (a collection of symptoms that affect the mind and loss contact with reality), dementia (loss of cognitive functioning such as thinking, remembering, and reasoning to such extent that it interferes with a person’s daily life and activities), and essential hypertension (abnormal blood pressure that was not a result of a medical condition). A review of Resident 2’s MDS, dated 1/4/2023, indicated the resident’s cognition was severely impaired. Resident 2 required extensive assistance with one-person physical assist in bed mobility, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 2’s Change of Condition / Interact Assessment Form, dated 4/13/2023, indicated the resident had an increased agitation as evidenced by hitting staff and non-compliance with safety measures or precautions. On 4/13/2023 at 8:30 p.m., Resident 2’s physician was notified and at 9 p.m., the resident’s responsible party was notified. A review of Resident 2’s Change of Condition / Interact Assessment Form, dated 5/26/2023, indicated the resident had an episode of aggression by grabbing the face of another resident. On 5/26/2023 at 1:30 p.m., Resident 2’s physician and responsible party were notified. A review of Resident 2’s Care Plan on acute aggression, initiated on 5/26/2023, indicated an intervention to assess the cause and trigger of the behavior and attempt to reduce and eliminate the triggers. The care plan indicated the intervention to provide redirection as needed. A review of Resident 2’s Change of Condition / Interact Assessment Form, dated 5/31/2023, and 8/5/2023, indicated the resident had increased agitation. Resident 2’s physician and responsible party were notified. A review of Resident 2’s History and Physical, dated 6/26/2023, indicated the resident had aggressive behavior and did not have the capacity to understand and make decisions. A review of Resident 2’s Care Plan on self-care deficits and extensive assistance, initiated on 7/7/2023, indicated an intervention to provide a safe environment, maintain resident’s privacy and respect resident rights. A review of Resident 2’s Care Plan on increased agitation, revised on 8/5/2023, indicated an intervention to assess the cause and trigger of the behavior and attempt to reduce and eliminate the triggers. The care plan indicated the intervention to provide redirection as needed. A review of Resident 2’s Change of Condition / Interact Assessment Form, dated 9/12/2023, indicated that at 5:45 p.m., CNA informed the licensed nurse that Resident 1 and Resident 2 had an altercation that resulted in Resident 2’s four cm by four cm skin tear on the left forearm with scant bleeding. On 9/12/2023 at 6:30 p.m., Resident 2’s physician and responsible party were notified. A review of Resident 2’s Physician Orders, dated 9/13/2023, indicated a left arm skin avulsion, to cleanse with normal saline, pat dry, then apply steri-strips, and keep steri-strips for 7 days. A review of the facility’s TV room and Dining Room Lunch and Dinner resident seats, dated 9/12/2023, indicated that Resident 1 and Resident 2 were assigned to share one table in the dining room. On 9/21/2023 at 10:55 a.m., during an interview, Activity Assistant (AA) stated that Resident 1 and Resident 2 were seated side by side within each other’s reach. AA stated that three tables were put together with four residents seated on one side of the table. AA stated that most of the time there were 30 residents from station 1 and station 2 in the TV room at dinner time. AA stated she did not witness Resident 1 and Resident 2’s physical altercation. AA stated that Certified Nursing Assistant 1 (CNA 1) informed her that Resident 1 and Resident 2 were bleeding from the arm and both residents were assisted to the nurse station for wound treatment. On 9/21/2023 at 1:24 p.m., during a telephone interview, Registered Nurse 1 (RN 1) stated that four to five activity staff and CNAs supervised the residents in the TV room. RN 1 stated that there were usually 30 residents in the TV room during dinner time and was very crowded. On 9/21/2023 at 2:55 p.m., during a concurrent interview and observation of the surveillance video recording on 9/12/2023, the Assistant Director of Nursing (ADON) stated that Resident 1 and Resident 2 were seated side by side in the TV room. The ADON stated that there were four tables attached together forming one long table with five residents and one facility staff seated on one side of the table. The ADON stated that the residents were within each other’s reach. On 9/22/023 at 8:49 a.m. during a concurrent interview and observation of the surveillance video recording on 9/12/2023, the Interim Director of Nursing (IDON) stated camera 16 indicated that at 5:35:46 p.m. Resident 2 had the left arm raised and was facing Resident 1. The IDON stated that Resident 2 started hitting Resident 1 on the right arm and Resident 1 hit Resident 2’s left arm. The IDON stated that at 5:36:08 p.m. Resident 2 grabbed and pulled Resident 1’s right arm while Resident 1 grabbed and pulled Resident 2’s left arm. The IDON stated that the surveillance video recording indicated there were five facility staff present in the TV room during the incident and none responded to Resident 1 and Resident 2. The IDON stated that at 5:36:55 p.m., Resident 2 hit Resident 1 again on the right arm. The IDON stated that at 5:42:28 p.m., CNA 1 saw Resident 2’s left arm and Resident 1’s right arm. CNA 1 and AA assisted Resident 1 and Resident 2 to Nursing Station 1. On 9/22/2023 at 12:22 p.m., during a follow up interview, the IDON stated that she was not aware of Resident 2’s aggressive behavior and Resident 1’s agitation. The IDON further stated that residents should not be seated within each other’s reach. A review of the facility’s policy and procedure titled, “Safety and Supervision of Residents,” last revised on 9/15/2023, indicated that the facility strives to make environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The policy indicated that the facility had an individualized, resident-centered approach to safety which addresses safety and accident hazards for individual residents. The policy indicated that the facility’s approach to safety was resident supervision as the core component. The type and frequency of resident supervision were determined by the individual resident’s assessed needs and identified hazards in the environment. The facility failed to provide supervision for Resident 1 and Resident 2, who were assessed with agitation and aggressive behavior, to prevent a physical altercation between both residents and injuries. On 9/12/2023 at 5:35 p.m., in the TV room in the presence of five facility staff, none of the five staff members present in the TV room responded to stop the physical altercation between Resident 1 and Resident 2. As a result, Residents 1 and 2 sustained skin tears from the physical altercation. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result Resident 1.