Other·February 1, 2024

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 12/18/2023 the California Department of Public Health made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about abuse. The facility failed to ensure Resident 2 had the right to be free from physical abuse (willful infliction of injury resulting physical harm, pain, or mental anguish) on 12/6/2023 at 7 a.m. when Resident 1, who had recent history of striking out, was impulsive, aggressive and was able to walk around unassisted, hit Resident 2 several times on the face and body. As a result, Resident 2 was subjected to physical abuse by Resident 1 while under the care of the facility, causing Resident 2 to have a nosebleed, generalized pain, nasal pain, and requiring first aid. Resident 2 manifested feelings of anxiety and feeling physically and emotionally violated. A review of Resident 2’s Admission Record indicated the facility initially admitted the 67-year-old resident on 11/22/2023 with diagnoses including hypertensive heart disease, anxiety disorder, and major depressive disorder. A review of Resident 2’s History and Physical exam, completed by the attending physician upon admission, dated 11/22/2023, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2’s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 11/28/2023, indicated Resident 2 had some memory problems and was able to make her needs known. Resident 2 was able to walk and transfers without the use of a wheelchair or another mobility device. The Mood Section of the MDS indicated Resident 2 had little interest or pleasure in doing things, was feeling depressed, or hopeless. A review of Resident 2’s Situational-Background-Assessment-Recommendation (SBAR, communication form between members of the health care team caring for a resident about his/her condition), dated 12/6/2023, indicated Resident 2 was observed with blood on the nose (no time specified). Resident 2 claimed Resident 1 hit her. The SBAR indicated Resident 2 required first aid treatment to stop the bleeding, pain medication, and emotional support. A review of Resident 2’s Departmental Notes (nursing notes), dated 12/6/2023, indicated the following: - At 7 a.m., Resident 1 hit Resident 2 in the face three times and Resident 2 was heard shouting for help. - At 11:10 a.m., Resident 2 verbalized generalized pain with an intensity of seven over 10 (7/10, on a pain scale from zero to 10, zero indicating no pain and 10 the worst pain possible). - At 11:37 a.m., Resident 2 complained of nasal pain and pain medication and non-medication interventions (such as applying ice pack to the affected area) were provided but not effective. Resident 2’s attending physician was informed and ordered X-rays of Resident 2’s facial (relating to the face) bones and pain medication every six hours as needed for pain. - At 12:51 p.m., indicated Resident 2 talked with the Social Service Director (SSD) and stated feeling safe in the facility after Resident 1 was taken by the police. - At 10:42 p.m., indicated the X-ray results were received and Resident 2 had no broken facial bones. A review of Resident 2’s Medication Administration Record (MAR) for the month of 12/2023, indicated Resident 2 was monitored for behavior of anxiety manifested by physical restlessness. Resident 2 had two episodes of anxiety on 12/6/2023 and 12/7/2023. Resident 2’s anxiety increased to three episodes on 12/8/2023 and 12/9/2023. A review of Resident 1’s Admission Record indicated the facility admitted the 61-year-old resident on 1/26/2021 and readmitted on 11/22/2023 with diagnoses including schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood) and type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 1’s MDS, dated 10/18/2023, indicated Resident 1 had impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident 1 was able to walk and transfer without the use of a wheelchair or other mobility device. The MDS Behavior Section indicated Resident 1 had verbal behavior symptoms such as threatening, screaming, and cursing directed toward others. Resident 1 was also assessed as manifesting hallucination (the experience of seeing, hearing, feeling, or smelling something that does not exist) and delusions (a false belief or opinion). A review of Resident 1’s SBAR, dated 11/8/2023, indicated Resident 1 was observed eating other resident’s (not identified) food. Resident 1 hit a staff member (not identified) on the back when she (staff member) took the food tray away from Resident 1. A review of Resident 1’s Departmental Notes for 1/15/2023 and 11/17/2023, indicated Resident 1 was sent to the hospital twice due to behavioral problems: - On 11/15/2023, at 1:45 p.m., Resident 1 was sent to General Acute Care Hospital 1 (GACH 1) and returned on the same day at 8:15 pm. - On 11/17/2023, at 4:24 p.m., Resident 1 was sent to GACH 2 and returned on 11/22/2023. A review of Resident 1’s Psychiatric (related to the study of mental illness) Evaluation, dated 11/23/2023 (a day after re-admission), indicated Resident 1 had poor impulse control and poor judgment. Resident 1 was receiving routine (regular) and as needed psychotropics (medications that affect the mind, emotions, and behavior). The Psychiatric Evaluation Assessment Section indicated Resident 1 was impulsive, yelling, and striking out towards staff. A review of Resident 1’s Departmental Notes, dated 12/6/2023, indicated that: - At 7:16 a.m., Resident 1 was monitored 1 on 1 (1:1, one staff with the resident always) because of violent behavior to others. - At 8:30 a.m., the police picked up Resident 1. On 12/18/2023 at 9:56 a.m., during an interview, Resident 2 stated that the day of the incident (did not recall the exact date), she saw Resident 1 in her (Resident 2) room, sitting on her (Resident 2) bed, drinking her (Resident 2) soda. Resident 2 said she told Resident 1 to get out of the room and then, Resident 1 threw the soda, punched her (Resident 2) on the face about five times, then punched her (Resident 2) on the body and threw her (Resident 2) on the floor. Resident 2 stated she was yelling for help, but nobody came. Resident 2 said that Resident 1 left the room, and she (Resident 2) was able to get up from the floor and noticed blood on her face. Resident 2 stated she went out of the room and saw a staff (Housekeeper 1 [HKP 1]), who assisted her to go to the SSD’s office. Resident 2 stated the nurses cleaned her face, applied ice pack, and gave her pain medications. Resident 2 stated that she felt physically and emotionally violated. Resident 2 stated she had to be more cautious because she does not know if someone else will unexpectedly do the same thing to her again. On 12/18/2023 at 10:21 a.m., during an interview, HKP 1 stated that on 12/6/2023, at around 7 a.m., she heard someone saying “help” and saw Resident 1 coming out of Resident 2’s room. HKP 1 stated that Resident 2 walked out of the room with the resident’s (Resident 2) hands on the face and there was blood on Resident 2’s hands and face mask. HKP 1 stated she assisted Resident 2 to the SSD’s office. On 12/18/2023 at 10:33 a.m., during an interview, the SSD stated that on 12/6/2023, she came to work at 5 a.m. and was in her office when around 7 a.m., HKP 1 brought Resident 2 to her office, who had a bloody nose. The SSD stated Registered Nurse 1 (RN 1) was walking by and assisted Resident 2. The SSD stated Resident 2 reported to her (SSD) that Resident 1 was in her room and punched her on the face. SSD also stated that Certified Nursing Assistant 3 (CNA 3) from the night shift went to Resident 1’s room after the incident with Resident 2, and Resident 1 hit CNA 3. SSD stated she called the police and Resident 1 was taken by the police. On 12/19/2023 at 9:15 a.m., during an interview, the Director of Nursing (DON) stated that the physical altercation incident (12/6/2023) between Residents 1 and 2 was the first. The DON stated Resident 2 sustained physical harm from the physical abuse inflicted by Resident 1. A review of the current facility provided policy and procedure titled, “Abuse Prevention Program,” dated 1/2023, indicated that as part of the resident abuse prevention, the administration will protect the resident from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. A review of the current facility provided policy and procedure titled, “Resident Rights,” dated 1/2023, indicated that federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident’s right to be free from abuse, neglect, misappropriation of property (is the unauthorized or improper use of someone else’s property or funds, usually for personal gain or advantage), and exploitation (the action of treating someone unfairly for your advantage). The facility failed to ensure Resident 2 had the right to be free from physical abuse on 12/6/2023 at 7 a.m. when Resident 1, who had recent history of striking out, was impulsive, aggressive and was able to walk around unassisted, hit Resident 2 several times on the face and body. As a result, Resident 2 was subjected to physical abuse by Resident 1 while under the care of the facility, causing Resident 2 to have a nosebleed, generalized pain, nasal pain, and requiring first aid. Resident 2 manifested feelings of anxiety and feeling physically and emotionally violated. The above violations had a direct relationship to the health, safety, or security of Resident 2.